SSA-4734-BK 2017-2024 free printable template

Form SSA-4734-BK 08-2017 Discontinue Prior Editions Social Security Administration Page 1 of 7 PHYSICAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT SOCIAL SECURITY NUMBER CLAIMANT NUMBERHOLDER IF CDB OR DWB CLAIM PRIMARY DIAGNOSIS RFC ASSESSMENT IS FOR Date 12 Months After Onset Current Evaluation Date SECONDARY DIAGNOSIS Date Last Insured OTHER ALLEGED IMPAIRMENTS Other Specify 1. LIMITATIONS For Each Section A - F Base your conclusions on all evidence in file clinical and laboratory findings...

How to fill out functional capacity assessment pdf

How to fill out ssa 4734 bk:

1. Begin by gathering all required information and documents, such as social security number, medical evidence, and employment history.
2. Fill out the applicant's personal information, including name, address, and contact details.
3. Provide details about the disability or medical condition that prevents the applicant from working.
4. List all medical treatments, medications, and doctors involved in the applicant's treatment.
5. Describe the applicant's work history, including past jobs, dates of employment, and the type of work performed.
6. Include any vocational rehabilitation programs or training the applicant has undergone.
7. If the applicant is receiving workers' compensation or other benefits, provide the details.
8. Sign and date the completed form.
9. Submit the form to the Social Security Administration (SSA) by mailing it to the designated address or delivering it in person.

Who needs ssa 4734 bk:

1. Individuals who are unable to work due to a disability or medical condition.
2. Those who are seeking to apply for Social Security Disability Insurance (SSDI) benefits.
3. Individuals who require financial assistance as a result of their inability to work.
4. Anyone pursuing a claim for disability benefits through the SSA.
5. People who have been advised by their doctors or medical professionals that they are unable to work due to a disability.

People Also Ask about functional capacity assessment pdf

Who fills out the RFC form?

The residual functional capacity (RFC) questionnaire is usually completed by a DDS (Disability Determination Services) physician. Unfortunately, RFC forms completed by DDS doctors are often written to ensure that the claimant is denied disability benefits. You can also have your doctor fill out an RFC on your behalf.

Can my doctor fill out an RFC form?

The Disability Determination Services (DDS) physician completes the RFC form, but you can also have your own doctor fill out an RFC on your behalf. This can be helpful because forms completed by DDS physicians are typically written to be highly critical of claims for disability benefits.

Who fills out the physical residual functional capacity assessment?

The residual functional capacity form/questionnaire is most typically completed by a physician with the disability determination services, your own physician, or following a consultative exam with a doctor who works in some capacity for the Social Security Administration.

Can any doctor fill out a RFC form?

The Disability Determination Services (DDS) physician completes the RFC form, but you can also have your own doctor fill out an RFC on your behalf. This can be helpful because forms completed by DDS physicians are typically written to be highly critical of claims for disability benefits.

What is the residual mental functional capacity form?

Special Form Because of the complexity of mental disorder evaluation, a special Form SSA-4734-F4-SUP is to be used to document the mental residual functional capacity (RFC) decision, i.e., what an individual can do despite his /her impairment.

How can I get a RFC form?

You can request the RFC form from your local Social Security office or you can download it directly from the Social Security website. Once you have obtained the form, take it with you to your doctor's office and have them complete the form for you.

For pdfFiller’s FAQs

What is ssa 4734 bk?

SSA 4734 BK is a form used by the Social Security Administration (SSA) to notify an individual that their benefits are being reduced or suspended because they are no longer eligible for them.

How to fill out ssa 4734 bk?

You can download the form (Form SSA-4734-BK) from the Social Security Administration's website and complete it by hand. The form requires information about your household income, employment status, and other financial information. Once the form is completed, you can mail it to the Social Security Administration or submit it online.

When is the deadline to file ssa 4734 bk in 2023?

The deadline to file Form SSA-4734-BK in 2023 is March 31, 2023.

Who is required to file ssa 4734 bk?

Form SSA-4734-BK, also known as the Request for Waiver of Overpayment Recovery or Change in Repayment Rate, should be filed by individuals who have received an overpayment of Social Security benefits and wish to request a waiver of repayment or a change in the repayment rate. This form is typically filed by beneficiaries who believe they are not at fault for the overpayment or for those who face financial hardship due to the repayment requirements.

What is the purpose of ssa 4734 bk?

The purpose of Form SSA-4734-BK (Adult Function Report) is to gather detailed information about the daily activities, abilities, and limitations of an individual who is applying for or receiving Social Security Disability benefits. The form is used by the Social Security Administration (SSA) to assess the individual's functional abilities and determine their eligibility for disability benefits. It asks questions about the individual's physical and mental health conditions, their ability to perform various activities such as walking, sitting, lifting, and handling objects, their ability to take care of personal needs, perform household chores, and engage in social interactions. The information provided on this form helps the SSA to evaluate the individual's functionality and make informed decisions regarding their eligibility for disability benefits.

What information must be reported on ssa 4734 bk?

The SSA 4734 BK is the form that is used to report information for a Continuing Disability Review (CDR) for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) recipients. This form collects information about the recipient's medical condition, work activity, and other relevant factors that may affect their eligibility for continued disability benefits. Specifically, the information that must be reported on the SSA 4734 BK includes: 1. Basic identifying information: This includes the recipient's name, Social Security number, contact information, and other personal details. 2. Change in medical condition: Any changes or updates in the recipient's medical condition since the last review must be reported. This includes information about new or worsening impairments, treatments, hospitalizations, medications, and consultations with healthcare providers. 3. Changes in work activity: Any changes in the recipient's work activity since the last review must be reported. This includes information about current employment, self-employment, volunteer work, or any other work-related activities or income. 4. Education and training: Information about the recipient's education, vocational training, or any vocational rehabilitation programs they may be participating in should be reported. 5. Miscellaneous changes: Any other changes or updates that may affect the recipient's eligibility for disability benefits should also be reported. This can include changes in marital status, living arrangements, financial resources, or any other relevant information. It is important to provide accurate and detailed information on the SSA 4734 BK form to ensure a thorough evaluation of the recipient's ongoing eligibility for disability benefits.

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