Form Ssa-199 - Vocational Rehabilitation Provider Claim
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1
2FORM APPROVED
SOCIAL SECURITY ADMINISTRATION
OMB No. 0960-0310
VOCATIONAL REHABILITATION PROVIDER CLAIM
To:
From:
Social Security Administration
Office of Employment Support Programs
VRA Operations Team
P.O. Box 17714
Baltimore, Maryland 21235-7714
VR Provider
Code
Check One
Claim Based On:
Continuous Period of SGA
Medical Recovery during VR
If claim is based upon other than a continuous period of SGA, it is not necessary to complete items 6, 8, 9, or 13 below.
Check One
Initial Claim
Reconsideration
Resubmittal
Supplemental
1. Client (First Name, MI, Last Name)
2.
SSN (Primary)
3. SSN (Widow or child, if appropriate)
4.
SSA
Blind
Non-Blind
SSI
8. Months Work Activity Tracked After VR
5a. Date Client Entered
5b. Date Signed IPE
7. Date of Final VR
6. Date Employment Began
VR OO
Closure
Closing (show months)
9. Medical services were provided, initiated, or coordinated under IWRP
Yes
No
10. Claim based solely on extended evaluation services (VR 06)
Yes
No
11. Direct cost during VR (after 9/30/81) -- Total from Item 17d (over)
$
12. Administrative, counseling and placement costs during VR (after 9/30/81)
$
13. Administrative costs only for tracking after VR (after 9/30/81)
$
14. Other (identify in Remarks section below)
$
15. Total amount claimed
$
16. What type of occupation(s) did the client perform during the continuous period of SGA:
Remarks:
Signature
Title
Date
Form SSA-199 (03-2010) EF (03-2010)
CONTINUED ON REVERSE SIDE
Destroy prior editions
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