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Omb 0960 0292-2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling in your personal information, including your name and Social Security Number. If applicable, provide the wage earner's details as well.
- In section B, answer the question regarding any recent medical treatment. If you have seen a doctor since the last update, select 'Yes' and list their names, addresses, and phone numbers along with the dates of treatment.
- Next, describe what these doctors have communicated about your condition in the provided space.
- If you have been hospitalized recently, indicate 'Yes' and provide the hospital's name and address. Include reasons for hospitalization and treatments received.
- Review all entries for accuracy before submitting. If more space is needed, feel free to use additional sheets.
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Related links
Mar 21, 2018 — This notice includes an extension of an OMB-approved information ... Recent Medical Treatment—20 CFR 404.1512 and 416.912—0960-0292.
New, revised, or extended information collections approved by OMB after that date can be found at ... 3060-0292, Part 69 and Sec. ... 3060-0960, Secs.
... Drug Agency information collection activities under OMB review', 5058, 5059 Administration; Health Resources and Services (4 documents) Administration; ...