Form SSA-454-BK, Continuing Disability Review Instructions

Provide an explanation or additional details related to the context of the question.

Provide an explanation for any activities you marked as needing help with or having difficulty doing. Use Section 9 – Remarks if you need more space.

Provide any additional information that was not included in earlier sections of the report. This can include details about your disability, its effects, or side effects from medications.

Select this checkbox if your residence address is not the same as your mailing address.

Select this checkbox if your residence address is the same as your mailing address.

Enter your mailing address, including street or PO Box and apartment number if applicable.

Enter the city of your mailing address.

Enter the state or province of your mailing address.

Check this box if you use an assistive device and complete the section below. Use Section 9 for additional space if needed.

Check this box if you do not use an assistive device. If you use it only outside your home, select 'always'.

Indicate if you have difficulty remembering things. Check the box if you need help or have difficulty with this activity.

Indicate if you have difficulty understanding or following directions. Check the box if you need help or have difficulty with this activity.

Provide your mailing address, including street or PO Box and apartment number if applicable.

Enter the city of your mailing address.

Enter the state or province of your mailing address.

Enter the ZIP or postal code of your mailing address.

Enter the country of your mailing address if it is not the USA.

Provide your residential address, including street and apartment number if applicable.

Enter the city of your residential address.

Enter the state or province of your residential address.

Enter the ZIP or postal code of your residential address.

Enter the country of your residential address if it is not the USA.

Provide your daytime phone number(s) where you can be reached, including area code or IDD and country code if outside the USA or Canada.

Enter the full name (First, Middle, Last, Suffix) of someone who knows about your medical condition(s) and can assist with your case.

Specify the relationship of the contact person to you, such as family member, friend, or neighbor.

Provide a secondary phone number if available.

Enter your email address.

Enter your ZIP or Postal Code. This is part of your address information.

Enter your country if you are not residing in the USA.

Provide your daytime phone number as previously described in section 1.F.

Enter the phone number of the medical facility or healthcare provider.

Enter your current phone number, including area code, where you can be reached.

Provide your current street address.

Enter the city of your current residence.

Enter the state or province of your current residence.

Enter the ZIP or postal code of your current residence.

If you reside outside the USA, enter your country of residence.

Enter the city of your current mailing address.

Enter the state or province of your current mailing address.

Enter the ZIP or postal code of your current mailing address.

Enter the country of your current mailing address if it is not the USA.

Enter your full mailing address.

Enter the date of your next contact, if any.

Enter the date of your last contact within the last 12 months, if known.

Provide the reason(s) for your contacts.

Enter the phone number associated with this contact or organization.

Enter the mailing address for this contact or organization.

Enter the city for this contact or organization's address.

Enter the state or province for this contact or organization's address.

Enter the ZIP or postal code for this contact or organization's address.

Enter the country for this contact or organization's address if it is not the USA.

Provide the name of a person who can be contacted regarding your disability review.

Provide a daytime phone number where you can be reached, including area code, and IDD and country codes if outside the USA or Canada.

Provide the mailing address, including street or PO Box and apartment number if applicable.

Enter the city of the mailing address.

Enter the state or province of the mailing address.

Enter the ZIP or postal code of the mailing address.

Enter the country of the mailing address if it is not the USA.

Select this checkbox if your medical conditions do not cause you difficulties in daily activities.

Select this checkbox if your medical conditions cause you difficulties in daily activities. Consider tasks you perform alone and without assistance.

Select this checkbox if you need help with or have difficulty dressing due to your medical conditions.

Select this checkbox if you need help with or have difficulty bathing due to your medical conditions.

Select this checkbox if you need help with or have difficulty caring for your hair due to your medical conditions.

Select this checkbox if you need help with or have difficulty walking due to your medical conditions.

Select this checkbox if you need help with or have difficulty standing due to your medical conditions.

Select this checkbox if you need help with or have difficulty sitting due to your medical conditions.

Select this checkbox if you need help with or have difficulty concentrating due to your medical conditions.

Select this checkbox if you need help with or have difficulty taking medicine due to your medical conditions.

Select this checkbox if you need help with or have difficulty preparing meals due to your medical conditions.

Select this checkbox if you need help with or have difficulty feeding yourself due to your medical conditions.

Select this checkbox if you need help with or have difficulty shopping due to your medical conditions.

Indicate if you have difficulty doing chores inside or outside of the house. Check the box if you need help or have difficulty with this activity.

Enter the year in the format YYYY.

Enter the year in the format YYYY.

Enter the year in the format YYYY.

Enter the year in which the event or change occurred.

Enter the month when the activity or treatment stopped.

Enter the year in YYYY format.

Enter the date completed or scheduled to be completed in MM format. If the exact date is not known, provide your best estimate.

Enter the year in which the event or action occurred.

Enter the month when the event or action began.

Enter the year in which the event or action occurred.

Enter the expected month of completion.

Enter the year in which the event or action occurred.

Enter the month when the event or action began.

Specify the frequency of use for braces. Check 'Always' if you use them all the time.

Specify the frequency of use for braces. Check 'Sometimes' if you use them occasionally.

Specify the frequency of use for canes. Check 'Always' if you use them all the time.

Specify the frequency of use for canes. Check 'Sometimes' if you use them occasionally.

Specify the frequency of use for crutches. Check 'Always' if you use them all the time.

Specify the frequency of use for crutches. Check 'Sometimes' if you use them occasionally.

Indicate whether you have received any education since your last disability decision.

Select this option if you have received education since your last disability decision and complete the following section.

Enter the name of the school you attended.

Enter the city where the school is located.

Enter the state or province where the school is located.

Enter the ZIP or postal code of the school's location.

Enter the country of the school's location if it is not in the USA.

Enter the year you started attending the school.

Enter the month you started attending the school.

Enter the year you finished attending the school.

Enter the month you finished attending the school. If the exact date is not known, provide your best estimate.

Enter the type of program or degree you pursued at the school.

Enter the year you completed or are scheduled to complete the program or degree.

Enter the month you completed or are scheduled to complete the program or degree. If the exact date is not known, provide your best estimate.

Check this box if the person receiving disability benefits is under age 14. Proceed to Section 10 if checked.

Check this box if the person receiving disability benefits is not under age 14. Proceed to Section 4 if checked.

Check this box if the person receiving disability benefits is under age 18. Proceed to Section 10 if checked.

Check this box if the person receiving disability benefits is not under age 18. Proceed to Section 5 if checked.

Indicate if you have difficulty managing money. Check the box if you need help or have difficulty with this activity.

This section contains the Paperwork Reduction Act Statement, explaining the time estimate for completing the form and where to send the completed report. Keep this information for your records.

Check this box if the answer is 'No' to the question being asked.

Provide the name of the health care provider who prescribed the aid or device, if known.

Provide the name of the health care provider who prescribed the aid or device, if known.

Provide the name of the health care provider who prescribed the aid or device, if known.

Provide the name of the health care provider who prescribed the aid or device, if known.

Provide the name of the health care provider who prescribed the aid or device, if known.

Provide the name of the healthcare provider or facility where the blood test (not HIV) was conducted.

Provide the name of the healthcare provider or facility where the breathing test was conducted.

Provide the name of the healthcare provider or facility where the cardiac catheterization was conducted.

Provide the name of the healthcare provider or facility where the EEG (brain wave test) was conducted.

Provide the name of the healthcare provider or facility where the EKG (heart test) was conducted.

Provide the name of the healthcare provider or facility where the hearing test was conducted.

Provide the name of the healthcare provider or facility where the HIV test was conducted.

Provide the name of the healthcare provider or facility where the speech/language test was conducted.

Indicate if you always use the specified aid or device for hearing.

Indicate if you sometimes use the specified aid or device for hearing.

This section provides instructions and important information about completing the SSA-454-BK form. It includes details on what information is needed, who can assist you, and how to contact the Social Security Administration for help. It also outlines what medical records are required and how they will be obtained.

Check this box if you can speak and understand English.

Check this box if you cannot speak and understand English.

If you cannot speak and understand English, specify your preferred language. An interpreter will be provided free of charge.

Check this box if you can read and understand English.

Select this checkbox if you cannot write more than your name in English.

Select this checkbox if you can write more than your name in English.

Select this checkbox if you cannot write more than your name in English.

Check this box if the person can speak and understand English.

Check this box if the person cannot speak and understand English.

If the person cannot speak and understand English, specify the preferred language here.

Specify the written language you use every day in most situations, such as at home, work, school, or in the community.

Indicate if you can read a simple message, such as a shopping list or short and simple notes, in the language you identified in 7.C. Check 'Yes' if you can.

Indicate if you cannot read a simple message, such as a shopping list or short and simple notes, in the language you identified in 7.C. Check 'No' if you cannot.

Indicate if you can write a simple message, such as a shopping list or short simple notes, in the language you identified in 7.C. Check 'Yes' if you can.

List the medical conditions that were treated or evaluated at the facility.

List each physical and/or mental health condition that limits your ability to work. If under age 18, list conditions that limit the child's ability to do the same things as other children the same age.

Continue listing additional physical and/or mental health conditions.

Continue listing additional physical and/or mental health conditions.

Continue listing additional physical and/or mental health conditions.

If you need more space to list additional conditions, refer to Section 9 – Remarks.

Indicate if you use braces as a medical device. Check the box if applicable.

Indicate if you use canes as a medical device. Check the box if applicable.

Indicate if you use crutches as a medical device. Check the box if applicable.

Indicate if you use any other medical device not listed. Check the box if applicable.

Indicate if you use eyeglasses as a medical device. Check the box if applicable.

Indicate if you use a hearing aid as a medical device. Check the box if applicable.

Indicate if you use a screen reader as a medical device. Check the box if applicable.

Indicate if you use a walker as a medical device. Check the box if applicable.

Indicate if you use a wheelchair as a medical device. Check the box if applicable.

Provide the name of any other medical device you use that is not listed.

Enter the name of the medical facility or office where you received treatment. If you don't have the full address, provide as much detail as possible.

Enter the street address of the medical facility or office.

Enter the city where the medical facility or office is located.

Enter the state or province where the medical facility or office is located.

Enter the ZIP or postal code of the medical facility or office.

Enter the country of the medical facility or office if it is not in the USA.

Check this box if you have not seen or received treatment from any healthcare provider in the last 12 months.

Check this box if you have seen or received treatment from a healthcare provider in the last 12 months and complete the following section.

Enter the year in which you were last seen by a healthcare provider, if known.

Enter the month in which you were last seen by a healthcare provider, if known.

Enter the month (MM) when you were last seen by the healthcare provider, if known.

Provide the name of the facility or office where you received medical treatment.

Enter the name of the healthcare provider who treated you.

Provide the phone number of the healthcare provider or facility.

List the medical conditions that were treated or evaluated during your visit.

Enter the street address of the healthcare facility or provider.

Enter the city where the healthcare facility or provider is located.

Enter the state or province where the healthcare facility or provider is located.

Enter the ZIP or postal code of the healthcare facility or provider.

If the healthcare facility or provider is not in the USA, enter the country.

Enter the year (YYYY) when you were last seen by the healthcare provider, if known.

Enter the month (MM) when you were last seen by the healthcare provider, if known.

Provide the name of the facility or office where you received medical treatment.

Enter the name of the healthcare provider who treated you.

Provide the phone number of the healthcare provider or facility.

List the medical conditions that were treated or evaluated during your visit.

Enter the street address of the healthcare facility or provider.

Enter the city where the healthcare facility or provider is located.

Enter the month you were last seen by a healthcare provider, if known, in the format MM.

Enter the name of the facility or office where you received treatment.

Enter the name of the healthcare provider who treated you.

Enter the phone number of the healthcare provider or facility.

Describe the medical conditions that were treated or evaluated.

Enter the street address of the healthcare provider or facility.

Enter the city where the healthcare provider or facility is located.

Enter the state or province of the healthcare provider or facility.

Enter the ZIP or postal code of the healthcare provider or facility.

Enter the country of the healthcare provider or facility if it is not in the USA.

Enter the month you were last seen by a healthcare provider, if known, in the format MM.

Enter the name of the facility or office where you received treatment.

Enter the name of the healthcare provider who treated you.

List the medical conditions that have been treated or evaluated since your last disability decision.

Provide the reason for taking this specific medicine, if you know it.

Provide the reason for taking this specific medicine, if you know it.

Provide the reason for taking this specific medicine, if you know it.

Enter the name of the medicine you are currently taking or have taken recently.

Enter the name of another medicine you are currently taking or have taken recently.

Enter the name of another medicine you are currently taking or have taken recently.

Enter the name of another medicine you are currently taking or have taken recently.

Enter the name of the health care provider who prescribed the treatment, if known.

Enter the name of the health care provider who prescribed the treatment, if known.

Enter the name of the health care provider who prescribed the treatment, if known.

Enter the name of the health care provider who prescribed the treatment, if known.

Enter the name of the healthcare provider who treated you.

Check this box if a vision test was provided as part of your services, tests, or evaluations.

Check this box if a psychological or IQ test was provided as part of your services, tests, or evaluations.

Check this box if work classes were provided as part of your services, tests, or evaluations.

Check this box if a hearing test was provided as part of your services, tests, or evaluations.

Check this box if a work evaluation was provided as part of your services, tests, or evaluations.

Check this box if other types of services, tests, or evaluations were provided and explain further.

List the body part that was biopsied, if known.

List the body part that was scanned using MRI or CT, if known.

List the body part that was X-rayed, if known.

Specify any other medical test or procedure not listed above.

Enter the name of the healthcare provider or facility where you underwent a treadmill exercise test.

Enter the name of the healthcare provider or facility where you had a vision test.

Enter the name of the healthcare provider or facility where you took a psychological or IQ test.

Enter the name of the healthcare provider or facility where you had a biopsy.

Enter the name of the healthcare provider or facility where you had an MRI or CT scan.

Enter the name of the healthcare provider or facility where you had an X-ray.

Enter the name of the healthcare provider or facility for any other medical tests not listed.

Select 'NO' if none of the listed providers ordered any medical tests for you in the last 12 months.

Select 'YES' if any of the listed providers ordered medical tests for you in the last 12 months. Provide details below.

Indicate whether you have taken or are currently taking any prescription or non-prescription medicines in the last 12 months. Check 'NO' if not applicable.

Indicate whether you have taken or are currently taking any prescription or non-prescription medicines in the last 12 months. Check 'YES' if applicable and provide details below.

Enter the name of the medicine you are taking or have taken.

If the medicine was prescribed, provide the name of the doctor who prescribed it, if known.

If the medicine was prescribed, provide the name of the doctor who prescribed it, if known.

If the medicine was prescribed, provide the name of the doctor who prescribed it, if known.

If the medicine was prescribed, provide the name of the doctor who prescribed it, if known.

Provide the reason for taking the medicine, if known.

Indicate if you have difficulty driving or using public transportation. Check the box if you need help or have difficulty with this activity.

Indicate if you always use the specified aid or device for walking.

Indicate if you sometimes use the specified aid or device for walking.

Indicate if you always use the specified aid or device for wheeling.

Indicate if you sometimes use the specified aid or device for wheeling.

Enter the name or organization related to this section.

Indicate if you always use the specified other aid or device.

Indicate if you sometimes use the specified other aid or device.

Check this box if no one else has your medical information or you are not scheduled to see anyone else.

Provide the full name (First, Middle, Last, Suffix) of the person receiving disability benefits. If you are filling out the form for someone else, enter their name.

Enter your Social Security Number. This is a unique identifier used by the Social Security Administration.

Select this checkbox if you have not used any other names on your medical or educational records in the last 12 months.

Select this checkbox if you have used other names on your medical or educational records in the last 12 months.

List any other names you have used on your medical or educational records.

Enter the state or province where you reside.

Enter your ZIP or postal code.

Enter your country if you are not residing in the USA.

Enter your Social Security claim number if you have one. This helps identify your case.

Enter the full name of the person completing this report, including first name, middle initial, and last name.

Describe the relationship of the person completing this report to the individual listed in section 1.ay.

Indicate if you have difficulty lifting objects. Check the box if you need help or have difficulty with this activity.

Indicate if you have difficulty using your arms. Check the box if you need help or have difficulty with this activity.

Indicate if you have difficulty using your hands or fingers. Check the box if you need help or have difficulty with this activity.

Enter your height in feet.

Enter your height in inches.

Enter your height in centimeters.

Enter your weight in pounds.

Enter your weight in kilograms.

Enter the name of the doctor who prescribed the medicine, if known.

Enter the name of the doctor who prescribed the medicine, if known.

Provide the reason for the prescribed medicine, if known.

Provide the reason for the prescribed medicine, if known.

Enter the name of the medicine you are taking.

This section provides information about the Privacy Act and how your personal information will be used and shared by the Social Security Administration. It is important to read and understand this statement.

Specify the type of program you are involved with, if applicable.

Provide the reason for stopping the plan or program.

Check this box if you are not still participating in the plan or program.

Check this box if you are still participating in the plan or program. Provide the best estimate if the date is not known.

Check this box if someone else is completing this report on behalf of the person listed.

Check this box if the person listed in section 1.ay is completing this report.

Enter the date when this report was completed, in the format of month, day, and year.

Check this box if the person listed in section 2.ay is completing this report.

Indicate if you always use the specified aid or device for screening.

Indicate if you sometimes use the specified aid or device for screening.

Check this box if you need to complete the following section below.

Check this box if you need to complete the following section below.

Indicate if you have difficulty seeing, hearing, or speaking. Check the box if you need help or have difficulty with this activity.

Indicate if you have difficulty getting along with people. Check the box if you need help or have difficulty with this activity.

Enter the date of your last medical disability decision. This information is for SSA use only and should not be filled in by the applicant.

Indicate whether you have participated in any support services, such as an Individualized Education Program, work plan, or vocational rehabilitation, since your last medical disability decision.

Enter the name of the facility or organization where you received support services.

Provide the phone number of the facility or organization where you received support services.

Enter the name of your counselor, instructor, or job coach associated with the support services.

Enter the city where the facility or organization providing support services is located.

Enter the state or province where the facility or organization providing support services is located.

Enter the ZIP or postal code for the facility or organization providing support services.

If the facility or organization is outside the USA, enter the country name.

Provide the mailing address, including street or PO Box, suite, building, etc., for the facility or organization providing support services.

Check this box if you have not received any specialized job, trade, or vocational training since your last disability decision.

Check this box if you have received specialized job, trade, or vocational training since your last disability decision and complete the following section.

Enter the name of the training facility where you received specialized training.

Enter the phone number of the training facility.

Enter the mailing address of the training facility.

Indicate if you always use the specified aid or device for vision.

Indicate if you sometimes use the specified aid or device for vision.

Check this box if you have worked since the date of your last medical disability decision. Complete the following section if checked.

Check this box if you have not worked since the date of your last medical disability decision. Proceed to 4.B. if checked.

Check this box if you are currently working.

Check this box if you are not currently working.

Check this box if you have been self-employed since your last medical disability decision.

Check this box if you have received wages from an employer since your last medical disability decision.