Fillable Form SSA-3441-BK DISABILITY REPORT - APPEAL

Fill Online, Printable, Fillable, Blank Form SSA-3441-BK DISABILITY REPORT - APPEAL Form

Use Fill to complete blank online SOCIAL SECURITY ADMINISTRATION (MD) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form SSA-3441-BK DISABILITY REPORT - APPEAL

On average this form takes 66 minutes to complete

The Form SSA-3441-BK DISABILITY REPORT - APPEAL form is 16 pages long and contains:

  • 0 signatures
  • 85 check-boxes
  • 223 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Social Security Administration

BROWSE SOCIAL SECURITY ADMINISTRATION (MD) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Form SSA-3441-BK (09-2019) UF
Discontinue Prior Editions
Social Security Administration
Page 1 of 10
OMB No. 0960-0144
DISABILITY REPORT - APPEAL
SSA-3441-BK
PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT
This report is used to update your information for your disability appeal. Completing this report accurately helps us
process your claim. Please complete as much of this report as you can.
IF YOU NEED HELP
Please do not ask your health care provider to complete this report. You can get help from other people, such as a
friend or family member. If you cannot complete this report, a Social Security representative can assist you. If you
make an appointment with us, please complete as much of this report as you can and have it with you for your
appointment.
HOW TO COMPLETE THIS REPORT
If you have Internet access, you may be able to complete this report online at
www.ssa.gov/disability/appeal
If you complete this report on paper:
•
Print or write clearly.
•
Include a ZIP or postal code with each address.
•
Provide complete phone numbers, including area code. If a phone number is outside the United States, also
provide International Direct Dialing (IDD) code and country code.
•
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 prescription medicine containers.
•
ANSWER EVERY QUESTION, unless this report indicates otherwise. You can write "don't know," or "none," or
"does not apply" if you need to.
•
If you need more space to answer any question, please use the REMARKS section on the last page, SECTION
10. Include the number of the question you are answering.
YOUR MEDICAL 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. Please tell us if you want us to return them to you. If you are having an interview in our office, bring your
medical records, your prescription medicine containers (if available), and this completed report with you.
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS THAT YOU DO NOT
ALREADY HAVE. With your permission, we will request your records. The information that you give us on this
report tells us where to request your medical and other records.
HOW TO SUBMIT THIS REPORT
Send or bring this completed report to your local Social Security office. If you have Internet access, you can locate
your nearest Social Security office by zip code at www.socialsecurity.gov/locator
. Our offices are also listed under
U.S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY
1-800-325-0778).
Form SSA-3441-BK (09-2019) UF Page 2 of 10
DISABILITY REPORT – APPEAL
For SSA use only. Please do not write in this box.
Related SSN ___________________________ Number Holder ___________________________
If you are filling out this report for someone else, please provide information about him or her. When a question refers to
“you” or “your,” it refers to the person who is applying for disability benefits.
SECTION 1 – INFORMATION ABOUT THE DISABLED PERSON
1. A. Name (First, Middle, Last, Suffix) 1. B. Social Security Number
1. C. Daytime Phone Number, including area code (include IDD and country codes if outside the U.S. or Canada)
Check this box if you do not have a phone number where we can leave a message.
1. D. Alternate Phone Number – another number where we may reach you, if any
1. E. Email Address (Optional)
SECTION 2 – CONTACTS
Give the name of someone (other than your doctors) we can contact who knows about your medical conditions, and can help
you with your claim. (e.g., friend or relative)
2. A. Name (First, Middle, Last) 2. B. Relationship to Disabled Person
2. C. Mailing Address (Street or PO Box), include apartment number or unit if applicable.
City State/Province ZIP/Postal Code Country (if not U.S.)
2. D. Daytime Phone Number, including area code (include IDD and country codes if outside the U.S. or Canada)
2. E. Can this person speak and understand English?
Yes No
If no, what language does the contact person prefer?
2. F. Who is completing this form?
The person who is applying for disability (Go to SECTION 3 - MEDICAL CONDITIONS).
The person listed in 2.A. (Go to SECTION 3 - MEDICAL CONDITIONS).
Someone else (Please complete the information below).
2. G. Name (First, Middle, Last) 2. H. Relationship to Disabled Person
2. I. Mailing Address (Street or PO Box) Include apartment number or unit if applicable.
City State/Province ZIP/Postal Code Country (if not U.S.)
2. J. Daytime Phone Number, including area code (include IDD and country codes if outside the U.S. or Canada)
SECTION 3 – MEDICAL CONDITIONS
3. A. Since you last told us about your medical conditions, has there been any CHANGE (for better or worse)
in your previously described physical or mental conditions?
Yes, approximate date change occurred: No
If yes, please describe in detail:
Form SSA-3441-BK (09-2019) UF
Page 3 of 10
Yes, approximate date of new conditions:
3. B. Since you last told us about your medical conditions, do you have any NEW physical or mental
conditions?
No
If yes, please describe in detail:
If you need more space, use SECTION 10 – REMARKS on the last page.
SECTION 4 – MEDICAL TREATMENT
4. A. Have you used any other names on your medical or educational records? Examples are maiden name,
other married name, or nickname.
Yes
No
If yes, please list the other names used:
4. B. Since you last told us about your medical treatment, have you seen a doctor or other health care
provider, received treatment at a hospital or clinic, or do you have a future appointment scheduled?
Yes No (Go to SECTION 6 – MEDICINES)
4. C. What type(s) of condition(s) were you treated for, or will you be seen for?
Physical Mental (including emotional or learning problems)
If you answered “Yes” to 4.B., please tell us who may have NEW medical records about any of your physical or mental
conditions (including emotional or learning problems).
Use the following pages to provide information for up to three (3) providers. Complete one page for each provider. If you
have more than three providers, list them in SECTION 10 - REMARKS on the last page.
Please include:
•
doctors' offices
•
hospitals (including emergency room visits)
•
clinics
•
mental health center
•
other health care facilities.
Only list the providers you have seen since you last told us about your medical treatment.
Form SSA-3441-BK (09-2019) UF Page 4 of 10
SECTION 4 – MEDICAL TREATMENT (continued)
Provider 1
4. D. Name of facility or office Name of health care provider who treated you
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone Number Patient ID# (if known)
Address
City
State/Province ZIP/Postal Code Country (if not U.S.)
Dates of Treatment (approximate date, if exact date is unknown)
Office, Clinic or Outpatient visits at
this facility
First Visit _________________
Last Visit _________________
Next scheduled appointment
(if any) ___________________
Emergency Room visits at
this facility
Date __________________
Date __________________
Date __________________
None
Overnight hospital stays at
this facility
Date in _______ Date out _______
Date in _______ Date out _______
Date in _______ Date out _______
None
What new or updated medical conditions were treated or evaluated?
What new or updated treatment did you receive for the above conditions? (Do not list medicines or tests in this box.)
Has this provider performed or sent you to any tests? Please include tests you are scheduled to have in the future.
Yes (Please complete the information below.) No (Go to the next page.)
Biopsy (list body part)
X-ray (list body part)
MRI/CT Scan (list body part)
___________________
EKG (heart test)
Other (please describe)
__________________
Hearing Test
DATES OF TESTS
Vision Test
Speech/Language Test
Breathing Test
EEG (brain wave test)
IQ Testing
HIV Test
Cardiac Catheterization
Blood Test (not HIV)
__________________
KIND OF TEST DATES OF TESTS
Treadmill (exercise test)
__________________
KIND OF TEST
go to SECTION 5 – OTHER MEDICAL INFORMATION on page 7.
If you do not have any more providers to describe,
If you need to list more tests, use SECTION 10 - REMARKS on the last page.
Form SSA-3441-BK (09-2019) UF Page 5 of 10
SECTION 4 – MEDICAL TREATMENT (continued)
Provider 2
4. D. Name of facility or office Name of health care provider who treated you
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone Number Patient ID# (if known)
Address
City
State/Province ZIP/Postal Code Country (if not U.S.)
First Visit _________________
Last Visit _________________
Next scheduled appointment
(if any) ___________________
Emergency Room visits at
this facility
Office, Clinic or Outpatient visits at
this facility
Date __________________
Date __________________
Date __________________
None
Overnight hospital stays at
this facility
Date in ________ Date out _______
Date in ________ Date out _______
Date in ________ Date out _______
None
Dates of Treatment (approximate date, if exact date is unknown)
What new or updated medical conditions were treated or evaluated?
What new or updated treatment did you receive for the above conditions? (Do not list medicines or tests in this box.)
Has this provider performed or sent you to any tests? Please include tests you are scheduled to have in the future.
No (Go to the next page.) Yes (Please complete the information below.)
Biopsy (list body part)
X-ray (list body part)
MRI/CT Scan (list body part)
___________________
EKG (heart test)
Other (please describe)
__________________
Hearing Test
DATES OF TESTS
Vision Test
Speech/Language Test
Breathing Test
EEG (brain wave test)
IQ Testing
HIV Test
Cardiac Catheterization
Blood Test (not HIV)
__________________
KIND OF TEST DATES OF TESTS
Treadmill (exercise test)
__________________
KIND OF TEST
go to SECTION 5 – OTHER MEDICAL INFORMATION on page 7.
If you do not have any more providers to describe,
If you need to list more tests, use SECTION 10 - REMARKS on the last page.
Form SSA-3441-BK (09-2019) UF Page 6 of 10
SECTION 4 – MEDICAL TREATMENT (continued)
Provider 3
4. D. Name of facility or office Name of health care provider who treated you
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone Number Patient ID# (if known)
Address
City State/Province ZIP/Postal Code Country (if not U.S.)
First Visit ___________________
Last Visit ___________________
Next scheduled appointment
(if any) _____________________
Emergency Room visits at
this facility
Office, Clinic or Outpatient visits at
this facility
Date ____________________
Date ____________________
Date ____________________
None
Overnight hospital stays at
this facility
Date in ________ Date out ________
Date in ________ Date out ________
Date in ________ Date out ________
None
Dates of Treatment (approximate date, if exact date is unknown)
What new or updated medical conditions were treated or evaluated?
What new or updated treatment did you receive for the above conditions? (Do not list medicines or tests in this box.)
Has this provider performed or sent you to any tests? Please include tests you are scheduled to have in the future.
No (Go to the next page.) Yes (Please complete the information below.)
Biopsy (list body part)
X-ray (list body part)
MRI/CT Scan (list body part)
___________________
EKG (heart test)
Other (please describe)
__________________
Hearing Test
DATES OF TESTS
Vision Test
Speech/Language Test
Breathing Test
EEG (brain wave test)
IQ Testing
HIV Test
Cardiac Catheterization
Blood Test (not HIV)
__________________
KIND OF TEST DATES OF TESTS
Treadmill (exercise test)
__________________
KIND OF TEST
If you need to list more tests, use SECTION 10 - REMARKS on the last page.
If you have been treated by more providers, use section 10 - REMARKS on the last page.
Form SSA-3441-BK (09-2019) UF Page 7 of 10
5. Since you last told us about your other medical information, does anyone else have medical information
about any of your physical or mental conditions (including emotional and learning problems) or are you
scheduled to see anyone else?
This may include:
•
workers’ compensation
•
vocational rehabilitation services
•
insurance companies who have paid you disability benefits
•
prisons and correctional facilities
•
attorneys
•
social service agencies
•
welfare agencies
•
school/education records
Yes (Please complete the information below.)
No (Go to SECTION 6 – MEDICINES)
SECTION 5 – OTHER MEDICAL INFORMATION
Name of Organization Claim or ID Number (if any)
Address
City State/Province ZIP/Postal Code Country (if not U.S.)
Name of Contact Person Phone Number
Date of First Contact Date of Last Contact Date of Next Contact (if any)
Reasons for Contacts
If you need to list more people or organizations, use SECTION 10 – REMARKS on the last page.
6. Are you currently taking any medicines (prescription or non-prescription)?
No (Go to SECTION 7 – ACTIVITIES)
Yes (Please complete the information below. You may need to look at your medicine containers.)
SECTION 6 – MEDICINES
NAME OF MEDICINE
IF PRESCRIBED,
NAME OF DOCTOR
REASON FOR MEDICINE
SIDE EFFECTS
YOU HAVE
If you need to list more medicines, use SECTION 10 – REMARKS on the last page.
Form SSA-3441-BK (09-2019) UF Page 8 of 10
If you need more space, use SECTION 10 – REMARKS on the last page.
SECTION 7 - ACTIVITIES
7. Since you last told us about your activities, has there been any change (for better or worse) in your previously described
daily activities due to your physical or mental conditions? (Examples of daily activities are household tasks, personal care,
getting around, hobbies and interests, social activities, etc.)
Yes
No
If yes, please describe in detail:
8. A. Since you last told us about your work, have you worked or has your work changed?
If yes, you will be asked to provide additional information.
Yes No
8. B. Since you last told us about your education, have you completed or are you enrolled in any type of
specialized job training, trade school, or vocational school?
Yes No
If yes, what type? ________________________________________________________________________________________
Date(s) attended: ________________________________________________________________________________________
SECTION 8 – WORK AND EDUCATION
If you need more space, use SECTION 10 – REMARKS on the last page.
9. Since you last told us about your vocational rehabilitation, have you participated, or are you participating in:
•
an individual work plan with an employment network under the Ticket to Work Program?
•
an individualized plan for employment with a vocational rehabilitation agency or any other organization?
•
a Plan to Achieve Self-Support (PASS)?
•
an individualized education program (IEP) through an educational institution (if a student age 18-21)?
•
any program providing vocational rehabilitation, employment services, or other support services to help you go to
work?
Yes (Please complete the information below.)
No (Go to SECTION 10 – REMARKS)
SECTION 9 – VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES
If you need more space, use SECTION 10 – REMARKS on the last page.
Name of Counselor, Instructor, or Job Coach
Address
City State/Province ZIP/Postal Code Country (if not U.S.)
Date when you started participating in the plan or program:
Name of Organization or School
Phone Number
Form SSA-3441-BK (09-2019) UF Page 9 of 10
SECTION 10 – REMARKS
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. Please be sure to include the number of the question you are answering (For example, 3A, 4D, etc.).
Date Report Completed MM/DD/YYYY:
Form SSA-3441-BK (09-2019) UF
Page 10 of 10
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1631(e) of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us
from reconsidering and reviewing your initial or continuing disability determination or evaluating any request for a
hearing.
We will use the information you provide to update your disability appeal information. The information we collect also
assists the State DDSs and administrative law judges in preparing for the appeals and hearings, and issuing a
determination or decision on an individual’s entitlement (initial or continuing) to disability benefits.
We may also share your information for the following purposes, called routine uses:
1. To State audit agencies for auditing State supplementation payments and Medicaid eligibility
considerations;
2. To third party contacts where necessary to establish or verify information provided by representative
payees or payee applicants; and
3. To Federal, State or local agencies for administering cash or non-cash income maintenance or health
maintenance programs.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example,
where authorized, we may use and disclose this information in computer matching programs, in which our records are
compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for
repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORNs) 60-0089, entitled
Claims Folders Systems; 60-0090, entitled Master Beneficiary Record; 60-0320, entitled Electronic Disability; and
60-0103, entitled Supplemental Security Income Record and Special Veterans Benefits. Additional information and a
full listing of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.
Paperwork Reduction Act
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by Section 2 of the Paperwork
Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management
and Budget control number. We estimate that it will take about 45 minutes to read the instructions, gather the facts,
and answer the questions. You may send comments on our time estimate above to: SSA, 6401 Security Boulevard,
Baltimore, MD 21235-6401. Send ONLY comments relating to our time estimate to this address, not the
completed form.
AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET AND KEEP IT FOR YOUR RECORDS.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form SSA-3441-BK DISABILITY REPORT - APPEAL

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 28 December 2019

Message

View Audit Log
Print With Audit Log
Duplicate Document