Form SSA-16-BK (01-2015) ef (01-2015)
FOR YOUR INFORMATION
An agency in your State that works with us in administering the Social Security disability program is
responsible for making the disability decision on your claim. In some cases, it is necessary for them to get
additional information about your condition or to arrange for you to have a medical examination at
Privacy Act Statement
Collection and Use of Information
Sections 202, 205, and 223 of the Social Security Act, as amended, authorize us to collect this information. We will
use the information you provide to determine if you or a dependent are eligible for insurance coverage and/or
The information you furnish on this form is voluntary. However, if you fail to provide all or part of the requested
information it may prevent us from making an accurate and timely decision concerning your or a dependent's
entitlement to benefit payments.
We rarely use the information you supply for any purpose other than determining benefit payments for you or a
dependent. However, we may use it for the administration and integrity of our programs. We may also disclose
information to another person or to another agency in accordance with approved routine uses, which include but are
not limited to the following:
1. To enable a third party or an agency to assist us in establishing right to Social Security benefits
2. To comply with Federal laws requiring the release of information from our records (e.g., to the Government
Accountability Office and Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State,
and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social
Security programs. (e.g., to the Bureau of Census and to private entities under contract with us).
We may also use the information you provide in computer matching programs. Matching programs compare our
records with records kept by other Federal, State, or local government agencies. Information from these matching
programs can be used to establish or verify a person's eligibility for federally-funded or administered benefit
programs and for repayment of incorrect payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Privacy Act Systems of Records Notices
entitled, Earnings Recording and Self Employment Income System (60-0059) and Claims Folders Systems
(60-0089). Additional information regarding these and other systems of records notices, are available on-line at
www.socialsecurity.gov or at your local Social Security office.
Paperwork Reduction Act Statement
- This information collection meets the requirements of 44 U.S.C. § 3507, as
amended by section 2 of the Paperwork Reduction Act of 1995 . You do not need to answer these questions
unless we display a valid Office of Management and Budget control number. We estimate that it will take about 20
minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED
FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through
SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in your
telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send
comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-0001 . Send only
comments relating to our time estimate to this address, not the completed form.