Disability Report - Child - Form SSA-3820-BK
READ ALL OF THIS INFORMATION BEFORE YOU BEGIN
COMPLETING THIS FORM THIS IS NOT AN APPLICATION
If you need help with this form, complete as much of it as you can, and your interviewer will help
you finish it.
The information that you give us on this form will be used by the office that makes the disability
decision on your disability claim. You can help them by completing as much of the form as
Fill out as much of this form as you can before your interview appointment. Print or write
DO NOT LEAVE ANSWERS BLANK. If you do not know the answers, or the answer is
"none" or "does not apply," write: "don't know," or " none," or "does not apply."
IN SECTION 4, PUT INFORMATION ON ONLY ONE DOCTOR/HMO/THERAPIST/ OTHER/
HOSPITAL/CLINIC IN EACH SPACE.
Each address should include a ZIP code. Each telephone number should include an
DO NOT ASK A DOCTOR OR HOSPITAL TO COMPLETE THE FORM. However, you can
get help from other people, like a friend or family member.
If your appointment is for an interview by telephone, have the form ready to discuss with us
when we call you.
If your appointment is for an interview in our office, bring the completed form with you or mail
ahead of time, if you were told to do so.
Be sure to explain an answer if the question asks for an explanation, or if you want to give
If you need more space to answer any questions or want to tell us more about an answer,
please use Section 10, "DATE AND REMARKS," on Pages 11 and 12, and show the number
of the question being answered.
If you have any of the following records for the child at home, send them to our office with your
completed forms or bring them with you to the interview. If you need the records back, tell us and
we will photocopy them and return them to you.
The child's medical records
The child's Individualized Education Program
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS
THAT YOU DO NOT ALREADY HAVE. With your permission, we will do that for you. The
information we ask for on this form tells us from whom to request medical and other records. If
you cannot remember the names and addresses of any of the doctors or hospitals, or the dates of
treatment, perhaps you can get this information from the telephone book, or from medical bills,
prescriptions and medicine containers.
Copies of the child's prescriptions or medicine containers
The child's Individualized Family Service Plan
ABOUT THE CHILD'S MEDICAL AND OTHER RECORDS
HOW TO COMPLETE THIS FORM
IF YOU NEED HELP
DISABILITY REPORT - CHILD - Form SSA-3820-BK