Add or replace text, adjust formatting, insert legally binding eSignatures, and send documents for signing without hopping between apps.
SSA HA-1151-BK 2009-2025 free printable template
Show details
Form HA-1151-BK 4-2009 ef 4-2009 Destroy Prior Editions Page 1 of 7 II. SITTING/STANDING/WALKING Please check how many hours the individual can if less than one hour how many minutes At One Time without Interruption Minutes Hours A. Form Approved OMB No* 0960-0662 SOCIAL SECURITY ADMINISTRATION OFFICE OF DISABILITY ADJUDICATION AND REVIEW MEDICAL SOURCE STATEMENT OF ABILITY TO DO WORK-RELATED ACTIVITIES PHYSICAL NAME OF INDIVIDUAL - To determine this individual s ability to do work-related...activities on a regular and continuous basis please give us your opinions for each activity shown below The following terms are defined as. REGULAR AND CONTINUOUS BASIS means 8 hours a day for 5 days a week or an equivalent work schedule. OCCASIONALLY means very little to one-third of the time. FREQUENTLY means from one-third to two-thirds of the time. CONTINUOUSLY means more than two-thirds of the time. Age and body habitus of the individual should not be considered in the assessment of...limitations. It is important that you relate particular medical or clinical findings to any assessed limitations in capacity The usefulness of your assessment depends on the extent to which you do this. I. LIFTING/CARRYING Check the boxes representing the amount the individual can lift and how often it can be lifted* Lift Never Occasionally up to 1/3 Frequently 1/3 to 2/3 Continuously over 2/3 A. Up to 10 lbs B. 11 to 20 lbs C. 21 to 50 lbs D. 51 to 100 lbs Carry Never Occasionally Identify the...particular medical or clinical findings i*e* physical exam findings x-ray findings laboratory test results history and symptoms including pain etc* which support your assessment or any limitations and why the findings support the assessment. Sit B. Stand C. Walk Total in an 8 hour work day If the total time for sitting standing and walking does not equal or exceed 8 hours what activity is the individual performing for the rest of the 8 hours Does the individual require the use of a cane to...ambulate Yes No If the answer is yes please answer the following How far can the individual ambulate without the use of a cane Is the use of a cane medically necessary With a cane can the individual use his/her free hand to carry small objects III. USE OF HANDS Indicate how often the individual can perform the following activites Right Hand ACTIVITY Left Hand REACHING Overhead All Other HANDLING FINGERING FEELING PUSH/PULL Which is the individual s dominant hand results history and symptoms...including pain etc* which support your assessment or any limitations and why the findings support this assessment. IV. USE OF FEET Right Foot up to 1/3 1/3 to 2/3 Left Foot Operation of Foot Controls V. POSTURAL ACTIVITIES How often can the individual perform the following activities Climb stairs and ramps Climb ladders or scaffolds Balance Stoop Kneel Crouch Crawl VI. DO ANY OF THE IMPAIRMENTS AFFECT THE CLAIMANT S HEARING OR VISION Not Evaluated If yes please complete the following questions...where appropriate 1. If a hearing impairment is present to communicate simple information b. Can the individual use a telephone to communicate 2.
pdfFiller is not affiliated with any government organization
Fill out, sign, and share forms from a single PDF platform
Manage all your documents quickly and securely in the cloud.
Edit and sign in one place
Create professional forms
Add and customize fillable fields to tailor each form to your needs and ensure easy completion without printing and scanning.
Simplify data collection
Quickly share forms via email or a secure link, enabling anyone to complete forms online in seconds, on any device.
Manage forms centrally
Keep all your forms and templates organized in one secure, cloud-based platform, track changes easily, and export documents in any format.
Why pdfFiller is the best tool for your documents and forms
End-to-end document management
From editing and signing to collaboration and tracking, pdfFiller has everything you need to get your documents done quickly and efficiently.
Accessible from anywhere
pdfFiller is fully cloud-based. This means you can edit, sign, and share documents from anywhere using your computer, smartphone, or tablet.
Secure and compliant
pdfFiller lets you securely manage documents following global laws like ESIGN, CCPA, and GDPR. It's also HIPAA and SOC 2 compliant.
How to fill out the SSA HA-1151-BK 2 printable form
Understanding Form HA-1151-BK
Form HA-1151-BK is a critical document in the process of applying for Social Security disability benefits. It serves to collect medical source statements about an individual's health conditions and limitations from their healthcare providers. This form is pivotal in the evaluation of a person's eligibility for disability benefits.
-
The HA-1151-BK form facilitates the Social Security Administration's (SSA) understanding of a claimant's medical condition.
-
This statement plays a vital role in the SSA's decision-making process on disability claims.
-
The form is specifically designed for use in Social Security claims and disability evaluations, adding to its significance.
What key sections are included in the form?
Form HA-1151-BK is structured into several key sections to facilitate thorough assessments of one’s medical capabilities. Each section focuses on different areas of analysis that are crucial in determining eligibility for benefits.
-
This section collects essential information about the claimant, including name, address, and social security number.
-
Information regarding the claimant's ability to lift and carry items is documented here, providing insight into their physical limitations.
-
This section assesses how long the individual can sit, stand, or walk, which is vital for understanding their mobility.
-
Details about medical findings that support the assessment of the claimant’s disability are outlined in this section.
How can you complete each section of the form?
Completing the HA-1151-BK form accurately is crucial for ensuring that your application is processed smoothly. Each section has specific requirements that should be followed closely.
-
Begin by carefully entering all personal information in Section A, ensuring accuracy to prevent delays.
-
Evaluate your lifting and carrying capabilities for Section B, documenting them truthfully to reflect your abilities.
-
In Section C, honestly record the total hours you can sit, stand, or walk to provide a comprehensive assessment.
-
For Section D, collaborate with your healthcare provider to ensure all medical findings are accurately documented.
How to edit and manage your form using pdfFiller?
pdfFiller offers an intuitive platform for uploading and managing your HA-1151-BK form digitally. Use its editing tools to make necessary adjustments easily.
-
Simply upload your completed HA-1151-BK form to pdfFiller and use the editing tools to make any changes.
-
Sign your document electronically to ensure it meets legal requirements, providing a secure method for submission.
-
Invite your healthcare provider to collaborate directly on the form, speeding up the completion process.
-
Utilize pdfFiller’s cloud storage capabilities to keep all documents organized and easily accessible.
What are the compliance notes and best practices?
Understanding compliance requirements is vital for the proper submission of the HA-1151-BK form. Paying attention to best practices can enhance your chances of approval.
-
The HA-1151-BK form requires OMB approval for use; familiarizing yourself with this context is essential.
-
Ensure that all assessments on the form are accurate and true to prevent any legal issues or complications.
-
Understanding the legal guidelines surrounding disability assessments can help maintain compliance and improve document integrity.
What interactive tools are available on pdfFiller?
pdfFiller provides various tools to help users complete forms efficiently and accurately. These tools can streamline the process significantly.
-
Access templates in pdfFiller to speed up the completion process for the HA-1151-BK form.
-
Utilize the available support services and frequently asked questions to guide you through the process.
-
pdfFiller can integrate with other platforms, enhancing document management and collaboration.
How to get feedback and assess document completion?
Receiving feedback on your completed HA-1151-BK form is crucial for ensuring comprehensive submissions. Digital tools can help track amendments and enhancements.
-
Consult with a professional to get insights on how well your form meets the necessary requirements.
-
Employ pdfFiller’s features to monitor any edits made to the document for effective quality control.
-
Regularly review and update your disability documentation to ensure compliance and relevance.
Frequently Asked Questions about medical source statement form
What is the purpose of the SSA HA-1151-BK form?
The SSA HA-1151-BK form serves to document medical source statements that assist the Social Security Administration in evaluating a claimant's eligibility for disability benefits.
How do I fill out Section B of the HA-1151-BK form?
In Section B, you need to assess your lifting and carrying capabilities. Provide realistic estimates based on your own experiences to reflect your physical limitations accurately.
Can I use pdfFiller for submitting my SSA HA-1151-BK form?
Yes, pdfFiller allows you to edit, eSign, and store your SSA HA-1151-BK form securely. You can also share it with others, like healthcare providers, for collaboration.
Why is it important to follow legal guidelines when completing the HA-1151-BK form?
Following legal guidelines ensures that your application is valid, minimizing the possibility of rejection or complications during the evaluation process.
What features does pdfFiller offer for form management?
pdfFiller provides a range of features including cloud storage, editing tools, eSigning capabilities, and templates that enhance the ease of managing your forms.
pdfFiller scores top ratings on review platforms
Truly like this product as is very efficient. PDFfiller is exactly what I needed and wish has discovered it before. Is very intuitive to use and is an amazing time saver. Definitely recommend this product.
It's a great product to use when you want to be paperless and be able to sign documents!
I am just starting to use it, but so far, so good
EASE OF USE WITH DOCUMENT FILLING IS EXCELLENT. tHE FORMS ARE NOT LINING UP WITH THE PREPRINTED 4-2S FOR 2017
STILL GETTING USED TO BUT SEEMS PRETTY SIMPLE
This is the first day of my subcription but so far it looks like exactly what i need
People Also Ask about form ha 1151 bk
Where can I get SSA form?
If you can't find the form you need, or you need help completing a form, please call us at 1-800-772-1213 (TTY 1-800-325-0778) or contact your local Social Security office and we will help you.
How do I get a copy of my SSA form?
Sign in to your my Social Security account to get your copy Creating a free my Social Security account takes less than 10 minutes, lets you download your SSA-1099 or SSA-1042S and gives you access to many other online services.
What is a SSA 10 form?
Form SSA-10. | Information You Need to Apply for Widow's, Widower's or Surviving Divorced Spouse's Benefits. Social Security Administration.
How can I get a SSA form?
You can apply: Online; or. By calling our national toll-free service at 1-800-772-1213 (TTY 1-800-325-0778) or visiting your local Social Security office. Call ahead to make an appointment.
What is the Social Security form to change citizenship status?
You can use Form SS-5 as your social security status change form when making the transition to U.S. citizenship. If you had an SSN card as a green card holder, you can then submit another SSA form SS5 and use it as your social security citizenship update form.
What is a SSA 827 form?
SSA and its affiliated State disability determination services use Form SSA-827, "Authorization to Disclose Information to the Social Security Administration (SSA)" to obtain medical and other information needed to determine whether or not a claimant is disabled.
Related pages
Related Content SSA HA-1151-BK
Related to SSA HA-1151-BK
Related Catalogs
If you believe that this page should be taken down, please follow our DMCA take down process
here
.
This form may include fields for payment information. Data entered in these fields is not covered by PCI DSS compliance.