Form HA-4631 | Claimant's Recent Medical Treatment

When you have requested, or are requesting, a hearing before an Administrative Law Judge (ALJ), use this form to tell us about medical treatment you have received since you, or someone on your behalf (for example, your representative or doctor), last furnished medical information to us.

HA-4631, Claimant's Recent Medical Treatment

If you are not certain whether you told us about treatment you have received, or remember treatment that you forgot to tell us about, include that information also.

Where to send this form

Đổi thẻ trò chơi và phần thưởngComplete the form and mail it to the hearing office where your claim is located. The address and telephone number of the hearing office are on the letter acknowledging receipt of the request for hearing that we sent.