OMB control number

Request for Evidence from Doctor or Hospital

OMB 0960-0722 · SSA.

OMB 0960-0722

Sections 223(d)(5) and 1614(a)(3)(H)(i) of the Social Security Act require claimants to furnish medical evidence of their disability when filing a disability claim. SSA uses Forms HA-66 and HA-67 to obtain medical evidence from medical sources identified by the claimants as having information relative to their impairments or ability to do work-related activities. In addition to accepting manual paper responses, SSA sends a barcode with the HA-66 and HA-67 allowing respondents to fax the information directly into the electronic claims folder rather than submitting it manually. SSA uses the information to determine eligibility for benefits. The respondents are medical sources, doctors, and hospitals that evaluate the claimants.

The latest form for Request for Evidence from Doctor or Hospital expires 2026-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form HA-66 Request for Medical Evidence From a Doctor (document unavailable) Form and Instruction
Form HA-67 Request for Medical Evidence From a Hospital Form and Instruction
Supporting Statement - 0757 (Final).docx (document unavailable) Supporting Statement A
Addendum 0960-0722.docx (document unavailable) Supplementary Document
HA-66 with Medical Source Information - paper submission Form and Instruction
HA-67 with Medical Source Information - electronic submission Other-Internet Screen
HA-67 with Medical Source Information - paper submission Form and Instruction
HA-66 with Medical Source Information - electronic submission Other-Internet Screen

All Historical Document Collections

202605-0960-001	Revision of a currently approved collection	2026-05-27
202011-0960-003	Revision of a currently approved collection	2020-11-06
201703-0960-014 Approved without change	Revision of a currently approved collection	2017-07-11
201402-0960-004 Approved without change	Extension without change of a currently approved collection	2014-05-28
201009-0960-004 Approved without change	Revision of a currently approved collection	2011-03-31
200708-0960-005 Approved without change	Revision of a currently approved collection	2008-03-13
200603-0960-009 Approved without change	Existing collection in use without an OMB Control Number	2006-03-21

OMB Details

HA-66 with Medical Source Information - paper submission

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Form HA-66

Request for Medical Evidence From a Doctor

Paper Only

Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.