Get SSA-3826-F4 2008
The information on this form under sections 205(a), 223(d)(5)(A), 1614(a)(3)(H)(i) and 1631(d)(1) of the Social Security Act. The information on this form is needed by Social Security to complete processing of the named patient's claim. While giving us the information on this form is voluntary, failure to provide the requested information may prevent an accurate or timely decision on the named patient's claim. Although the information you furnish on this form is almost never used for any purpose.
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