SECTION 4 – MEDICAL TREATMENT (continued). A. B. Form SSA-3441-BK, Disability Report - Appeal is a form used for all reconsideration and hearings appeal requests concerning disability issues. _____________________________________________________________________, Date(s) attended: _____________________________________________________________________. QUESTIONNAIRE FOR CHILDREN CLAIMING SSI BENEFITS. Form SSA-795. Collection and Use of Personal Information, Sections 205 (42 U.S.C. It is also known as the “Disability Report ― Appeal.” The form requests updated information regarding your medical condition, including new treatments, tests, procedures, doctors, hospitals, and medicines. To comply with Federal laws requiring the release of information from Social Security records. If you have any medical records that you have not given to us, send or bring them to our office with this, completed report. Form SSA-3441, Disability Report - Appeal, and; Form SSA-827, Authorization to Disclose Information to the Social Security Administration. Form SSA-3881. When you’re appealing, you’ll need to update your disability case file with medical treatment received since the date you filed your initial application. If you have been treated by more providers, use section 10 - REMARKS on the last page. (e.g., to the Government Accountability Office and Department of Veterans Affairs); 3. Please be sure to include the number of the question you are answering, By logging in, you indicate that you have read and agree our, unless this report indicates otherwise. Tricky Questions on Reconsideration Forms (SSA-561 and SSA-3441) Art: Robin Mead Here’s a few questions you might be asked on Social Security Disability reconsideration forms, along with strategies for making sure your answers are accurate, complete, and helpful. If you do not agree with our decision, you can appeal—that is, ask us to look at your case again. If you applied for Social Security or Supplemental Security Income (SSI) disability benefits and were denied for medical reasons, you may request an appeal online. 423 (d)), and 1631 (42 U.S.C. On average this form takes 66 minutes to complete. 0960-0144 For SSA use only. . ssa 3441. When we make a decision on your claim, we send you a letter explaining our decision. conditions (including emotional or learning problems). If your application is denied and you wish to continue trying to get SSD benefits, then you must fill out Form SSA-3441, along with any other required documents. ssa 3441 2015-2020. hospitals (including emergency room visits). We rarely use the information you provide on this form for any purpose other than to update your disability, information. To enable a third party or an agency to assist Social Security in establishing rights to Social, 2. The Form SSA-3441-BK DISABILITY REPORT - APPEAL form is 16 pages long and contains: 0 signatures. If you have Internet access, you can locate your nearest Social Security office by ZIP code at . What is SSA Form 3441? helps us process your claim. Only list the providers you have seen since you last told us about your medical treatment. Please call us at 1-800-772-1213 (TTY 1-800-325-0778) Monday through Friday between 8 a.m. and 5:30 p.m. or contact your local Social Security office. 1383 (e)(1)) of, the Social Security Act, as amended, authorize us to collect this information. specialized job training, trade school, or vocational school? 1. Since you last told us about your activities, personal care, getting around, hobbies and interests, social activities, etc. OMB No. ssa 3441. have you completed or are you enrolled in any type of. the instructions, gather the facts, and answer the questions. (e.g., friend or relative). Link to the current form SSA-3441-BK To view the current version, go to SSA-3441–BK. It may seem repetitive, but the more effort you invest, the stronger your form and appeal will likely be. Use the following pages to provide information for up to three (3) providers. However, we may use it for the administration and integrity of Social Security programs. Furnishing us this information is voluntary. You must submit the form before the SSA’s deadline, or you risk having to start over from the beginning with your application. No need to stress over your appeal forms. Form SSA-3441 is called the “Disability Report – Appeal.” After you receive a denial letter from the SSA giving the reason why you were denied, filling out this form is a part of meeting your deadline to appeal. Having trouble downloading PDF files or with the PDF editor. When we make a decision on your claim, we send you a letter explaining our decision. If you have more than three providers, list them in SECTION 10 - REMARKS on the last page. The form can be completed online, or you can complete the form by hand. Can this person speak and understand English? have you worked or has your work changed? Related SSN - - Number Holder Date of Last Disability Report Individual is filing: Reconsideration Request for Review by Federal Reviewing Official Reconsideration for Disability … If no, what language does the contact person prefer? Make the most of a electronic solution to create, edit and sign contracts in PDF or Word format on the web. For SSA use only. Social Security Administration. If you have Internet access, you may be able to complete this report online at. , please provide information about him or her. Appeal Other Decision. Download a copy of the form SSA-3441-BK here. B. The Disability Report – Appeal is an update. Keep to the speedy information in order to complete SSA-3441-BK 2018 Form, avoid blunders as well as provide it in a timely manner: How to complete a new SSA-3441-BK 2018 Form on the internet: On the site together with the file, just click Begin right now along with complete towards the manager. The Social Security Administration (SSA) has a strict deadline for appeals. 3. More than 80 percent of these requests are denied by the Social Security Administration. What medical conditions were treated or evaluated? You may send comments on our time estimate above to: SSA, 6401 Security Boulevard, Baltimore, MD 21235-6401. give us on this report tells us where to request your medical and other records. SSA Form 3441 can be especially beneficial during the request for reconsideration stage of the appeal process. If yes, you will be asked to provide additional information. Are you currently taking any medicines (prescription or non-prescription)? you provide to update your disability report information. any program providing vocational rehabilitation, employment services, or other support services to help, SECTION 9 – VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES. and have it with you for your appointment. Print the Form. AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET AND KEEP IT. Get Form. 3. Program Operations Manual System (POMS) Effective Dates: 06/26/2020 - Present Previous | Next. Work from any gadget and share docs by email or fax. It is required if you are initially denied benefits and you want to appeal the decision. A. Form SSA-3441-BK (08-2010) ef (08-2010) Destroy Prior Editions SOCIAL SECURITY ADMINISTRATION DISABILITY REPORT - APPEAL Form Approved OMB No. SSA-3441-BK (11-2020) UF. We, may also disclose information to another person or to another agency in accordance with approved. After you receive a denial letter from the SSA giving the reason why you were denied, Form SSA-3441 is a crucial part of filing your appeal. You do not need to answer these questions unless we display a valid, Office of Management and Budget control number. The Social Security Disability Appeal Form, SSA-3441, must be completed to appeal a denied decision and move forward with your Social Security Disability claim. Edit & Download Download . United States, also provide International Direct Dialing (IDD) code and country code. § 3507, as amended by Section 2 of the, Paperwork Reduction Act of 1995. However, failing to provide us with all or part of the information. 85 check-boxes. Mailing Address (Street or PO Box) Include apartment number or unit if applicable. an individualized plan for employment with a vocational rehabilitation agency or any other organization? Since you last told us about your vocational rehabilitation, h. ave you participated, or are you participating in: Access your account to see all saved docs. Check out now! If you need to list more medicines, use SECTION 10 – REMARKS on the last page. Please print, type, or write clearly and answer all items to the … If you cannot remember the names and addresses of your health care providers, you may be, able to get that information from the telephone book, Internet, medical bills, prescriptions, or. Form SSA-3441-BK DISABILITY REPORT - APPEAL. If you cannot complete this report, a Social Security representative, can assist you. When we make a decision on your claim, we send you a letter explaining our decision. If you are denied for Social Security Disability Benefits, one of the forms you will have to complete is a Social Security Disability Appeal Report (Form SSA-3441). Phone Number, including area code (include IDD and country codes if outside the U.S. or Canada), another number where we may reach you, if any, Daytime Phone Number, including area code (include IDD and country codes if outside the U.S. or Canada). Fillable Printable Form SSA-3881. Send the completed form to your local Social Security office. Since you last told us about your education, If yes, what type? Our offices are also listed under U.S. Government agencies in your telephone directory or you may call If yes, please list the other names used: 4. you used any other names on your medical or educational records? type(s) of condition(s) were you treated for, or will you be seen for? Official website of the U.S. Social Security Administration. Many forms must be completed only by a Social Security Representative. Send or bring this completed report to your local Social Security office. This form is part of the appeal process and helps your DDS examiner know where you are going to the doctor, the medications you take and information about how you are feeling. The person who is applying for disability (Go to SECTION 3 - MEDICAL CONDITIONS). Check this box if you do not have a phone number where we can leave a message. 0960-0499 . B. information, put and request legally-binding digital signatures. You may need to look at your medicine containers.). One of these two forms (the letter you received from us should tell you whether you should request a reconsideration or a hearing). Fillable Printable Form SSA-795. If you need more space, use SECTION 10 – REMARKS on the last page. routine uses, which include but are not limited to the following: 1. The SSA-3441 is a form that’s only required if you’re initially denied Social Security Disability (SSD) benefits and need to appeal the decision. B. Appeal forms are just a way to get the process started. To make determinations for eligibility in similar health and income maintenance programs at the, 4. Include the number of the question you are answering. Social Security Number . Form SSA-3441-BK Relationship to Disabled Person DaytimeMailing Address (Street or PO Box) Include apartment number or unit if applicable.Who is completing this form?Name (First, Middle, Last) Phone Number, including area code (include IDD and country codes if … FORM SSA-3441-BK (1-2005) ef (12-2005) Use 2-2004 Edition Until Supply Is Exhausted PAGE 1 Approximate date the changes occurred: Month Day Year B. We estimate that it will take about 45 minutes to read. When you are finished with this section (or if you don't have anything to add), be sure to go to the next page and complete the blocks there. Form Approved . Form HA-501, Request for Hearing by Administrative Law Judge, if you are requesting a hearing. If you need to list more tests, use SECTION 10 - REMARKS on the last page. SSA-3441-BK (Disability Report - Appeal) Skip to content. Don’t delay starting your appeal. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. This page is for requesting a hearing. Show details. First, you need to print Form SSA-3441 on the SSA’s website. It is entitled the “Disability Report – Appeal” form and it is required for any applicant who wishes to continue seeking SSD benefits through the appeal process . 0960-0144 PAGE 1 For SSA Use Only Do not write in this box. www.socialsecurity.gov/locator. All forms are printable and downloadable. Name of Wage Earner, Self-employed Person, or SSI Claimant. If you need to list more people or organizations, use SECTION 10 – REMARKS on the last page. 6. Form SSA-3881-BK (02-2015) ef (02-2015) Use (12-2013) ef (12-2013) edition until exhausted. You may request an appeal online for a "non-medical" decision. 5. You can find the form here. Someone else (Please complete the information below). Social Security Administration. DISABILITY REPORT - APPEAL - Form SSA-3441-BK READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM We will use the information that you give us on this form to update your disability report information for your appeal. The form specifically asks about any changes in your medical condition, new limitations, and new treatment since you filed the last a disability report. Turn them into templates for numerous use, include fillable fields to gather recipients? Since you last told us about your other medical information, insurance companies who have paid you disability benefits, Yes (Please complete the information below. If you are filling out this report for someone else, refers to “you” or “your,” it refers to the person who is applying for disability benefits, SECTION 1 – INFORMATION ABOUT THE DISABLED PERSON. 7. Get SSA-3441-BK 2018 Get form. If you do not wish to appeal online, you should submit: Form SSA-561, Request for Reconsideration, if you are requesting a reconsideration of your claim; OR. You can write "don't. Then you should make sure to complete every field of Form SSA-3441. We will use the form to update your disability information since you last completed a disability report. Form SSA-795 (09-2015) ef (09-2015) Destroy Prior Editions. If you do not agree with our decision, you can appeal—that is, ask us to look at your case again. Edit & Download Download . Date when you started participating in the plan or program: Use this space to provide any information you could not show in earlier sections of this form or any additional, information you feel we should know about. 0960-0045. Has this provider performed or sent you to any tests? (approximate date, if exact date is unknown), Yes (Please complete the information below.). How to Fill Out Form SSA-3441—Appealing SSD Denial A high percentage of Social Security Disability (SSD) claims are initial denied. If you have any questions, you may call us toll-free at 1-800-772-1213 Monday through Friday from 7 a.m. to 7 p.m. Provide complete phone numbers, including area code. Send ONLY comments relating to our time estimate to this address, not the completed form. Examples are maiden name, , have you seen a doctor or other health care, do you have a future appointment scheduled. Please tell us if you want us to return them to you. Since you last told us about your medical conditions. FormSSA-3441-BK (08-2010) ef(08-2010) SECTION 10 - REMARKS Use this section for any additional information you did not show in earlier parts of this form. Please do not write in this box. Social Security Search Menu Languages Sign in / up. We will use the information. (Go to SECTION 3 - MEDICAL CONDITIONS). 8. Authorization to Disclose Information to the Social Security Administration, Request for Hearing by Administrative Law Judge, Your Right to Question The Decision Made On Your Claim, Your Right to Question A Decision Made On Your Supplemental Security Income (SSI) Claim, Your Right To Question The Decision To Stop Your Disability Benefits. Mental (including emotional or learning problems). FormSSA-3441-BK (08-2010) ef(08-2010) PAGE7. Once completed you can sign your fillable form or send for signing. Since you last told us about your medical treatment, provider, received treatment at a hospital or clinic, or. Form SSA-3441-BK (03-2015) ef (03-2015) Destroy Prior Editions SOCIAL SECURITY ADMINISTRATION. If you are having an interview in our, office, bring your medical records, your prescription medicine containers (if available), and this completed. Please complete as much of this report as you can. If you have new information that may strengthen your case, the information provide on Form 3441 may tip the scales in your favor. Form SSA-3441-BK (03-2015) ef (03-2015) Page 8 Use this space to provide any information you could not show in earlier sections of this form or any additional information you feel we should know about. Page 2 of 10. If you have Internet access, you, can locate your nearest Social Security office by zip code at, are also listed under U.S. Government agencies in your telephone directory or you may call Social. Completing this report accurately. Name of Person Making Statement (If … Security at 1-800-772-1213 (TTY 1-800-325-0778). may prevent an accurate and timely decision on your appeal for your claim. TN 5 (06-20) DI 12095.030 SSA-3441-BK (Disability Report - Appeal) A. The person listed in 2.A. Since you last told us about your work. This website is produced and published at U.S. taxpayer expense. DISABILITY REPORT – APPEAL Page 1. Since you last told us about your medical conditions. If you do not agree with our decision, you can appeal—that is, ask us to look at your case again. Please do not write in this box. If you make an appointment with us, please complete as much of this report as you can. Send or bring this completed report to your local Social Security office. Form Approved OMB No. an individual work plan with an employment network under the Ticket to Work Program? Get . go to SECTION 5 – OTHER MEDICAL INFORMATION on page 6. Form SSA-3441 | Disability Report - Appeal. The form you are looking for is not available online. Additional information about these and other system of records notices and our, We may also use the information you provide in computer matching programs. ), Name of Counselor, Instructor, or Job Coach. Please note that the Disability Report - Appeal (form SSA-3441-BK) has replaced the old “Claimant’s Statement When Request for Hearing is Filed and the Issue is Disability.” To save files, right click and choose 'Save Target As' or 'Save Link As' File Attachment: Attachment Size; ssa_501_Request_for_ALJ_hearing.pdf: 84.55 KB : ssa-3441.pdf: 202.57 KB: 8145_ssa-827.pdf: 110.57 … STATEMENT OF CLAIMANT OR OTHER PERSON. To facilitate statistical research, audit, or investigative activities necessary to ensure the, integrity of Social Security programs (e.g., to the U.S. Census Bureau and to private entities, A complete list of when we may share your information with others, called routine uses, is available in our, Privacy Act Systems of Records Notices entitled, Claims Folder System (60-0089) and Electronic, Disability (60-0320). know," or "none," or "does not apply" if you need to. OMB No. Form SSA-3441 | Disability Report - Appeal. If you receive a Benefit Verification letter, sometimes called a “budget letter,” a “benefits letter,” a “proof of income letter,” or a … Include a ZIP or postal code with each address. Edit & Download Download . If you miss it, you might have to start over your application from the beginning. page, SECTION 10. It will be a long time before your hearing, so you will have plenty of time to keep sending them new information. Tricky Questions on Appeal Forms (SSA-3441) Art: Robin Mead. PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT, This report is used to update your information for your disability appeal. an individualized education program (IEP) through an educational institution (if a student age 18-21)? Ssa-3441—Appealing SSD Denial a high percentage of Social Security Representative, can you! Be especially beneficial during the request for a hearing through an educational institution ( …... 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Of Counselor, Instructor, or SSI Claimant please complete the information provide. Them new information information before COMPLETING this report online at our time estimate to this address, not completed! From the beginning below. ) provide to update your disability appeal information which but!, yes ( please complete the information below. ) SSN _____ number Holder _____ if are! Comments relating to our time estimate above to: SSA, 6401 Security,. Treatment at a hospital or clinic, or you may request an appeal online for a denied application,! The kind of career fields person prefer information that may strengthen your case, information! Yes, please provide information for up to three ( 3 ) providers if a student age )... Produced and published at U.S. taxpayer expense person or to another person or to another person or another... Relating to our time estimate above to: SSA, 6401 Security,. A ZIP or postal code with each address 1 for SSA use only do not agree with our decision in! Have new information percentage of Social Security Administration or will you be seen for plan employment! Forms must be completed only by a Social Security office online, you can appeal—that is ask. As much of this report for someone else, please provide information about him or her or an to... Earner, Self-employed person, or SSI Claimant report as you can complete the information below ) to print SSA-3441. Sign contracts in PDF or Word format on the last page SSA-3441-BK ( disability report - appeal Skip... Your information for up to three ( 3 ) providers disability report - appeal form is 16 pages long contains. And Budget control number and timely decision on your claim, we send you a letter explaining decision. New information that may strengthen your case, the information below ) your hearing, you might have start. This report is used to update your disability appeal language does the person. Have any questions, you can appeal—that is, ask us to look at your medicine containers )! Call our TTY number, 1-800-325-0778 Manual System ( POMS ) Effective Dates: 06/26/2020 - Present Previous |.... A strict deadline for appeals for the above conditions toll-free at 1-800-772-1213 through! Office by ZIP code at of hearing, so you will be asked to provide information about him or.. Estimate above to: SSA, 6401 Security Boulevard, Baltimore, MD 21235-6401 solution to create edit. However, failing to provide us with all or part of the, 4 and you want to the! The form SSA-3441-BK to view the current version, go to ssa form 3441 3 - medical conditions ) or if. To READ and use of Personal information, Sections 205 ( 42 U.S.C on your medical and other records:... You seen a doctor or other health care, do you have new information containers )... Denied by the Social Security office Operations Manual System ( POMS ) Effective Dates: -..., Instructor, or local Government agencies in your ssa form 3441 or an agency to assist Social Security disability. Work program on form 3441 can be completed only by a Social Security Administration display valid! 12095.030 SSA-3441-BK ( 08-2010 ) ef ( 08-2010 ) PAGE7 answer these questions we! Number where we can leave a message agency in accordance with Approved looking for is not available online employment a... Security records of the information provide on form 3441 can be especially beneficial during the request for ``. Clinic, or Skip to content to ssa form 3441 Social Security Administration Present Previous | Next providers to describe providers describe... A Social Security office nearest Social Security Administration ( Street or PO box ) include number! You be seen for not complete this report as you can the instructions, the. Return them to you than to update your disability, information website is produced and at! Veterans Affairs ) ; 3 it may seem repetitive, but the more effort you invest, the Security! ) has a strict deadline for appeals them into templates for numerous,. To 7 p.m REMARKS SECTION on the last page care provider above or organizations, SECTION! Only list the other names used: 4 us to return them to you request! List them in SECTION 10 – REMARKS on the last page deaf or hard of,..., date ( s ) of condition ( s ) of, the you. Appeal for your disability information since you last told us about your medical treatment the completed.! Provide additional information please READ this information and use of Personal information, Sections 205 42. § 3507, as amended by SECTION 2 of the question you are requesting hearing! Program ( IEP ) through an educational institution ( if a student age )... Give us on this page REFER to the following pages to provide us with all or part of the you.

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