United States, also provide International Direct Dialing (IDD) code and country code. Please complete as much of this report as you can. Send ONLY comments relating to our time estimate to this address, not the completed form. Print the Form. Please tell us if you want us to return them to you. You may need to look at your medicine containers.). If you do not agree with our decision, you can appeal—that is, ask us to look at your case again. Social Security Administration. Turn them into templates for numerous use, include fillable fields to gather recipients? 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. You may request an appeal online for a "non-medical" decision. Link to the current form SSA-3441-BK To view the current version, go to SSA-3441–BK. Fillable Printable Form SSA-795. To enable a third party or an agency to assist Social Security in establishing rights to Social, 2. Many forms must be completed only by a Social Security Representative. Social Security Search Menu Languages Sign in / up. When we make a decision on your claim, we send you a letter explaining our decision. 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. If no, what language does the contact person prefer? 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. The form can be completed online, or you can complete the form by hand. Since you last told us about your other medical information, insurance companies who have paid you disability benefits, Yes (Please complete the information below. ssa 3441. If you have Internet access, you may be able to complete this report online at. If you are having an interview in our, office, bring your medical records, your prescription medicine containers (if available), and this completed. This website is produced and published at U.S. taxpayer expense. DISABILITY REPORT – APPEAL Page 1. If you miss it, you might have to start over your application from the beginning. Additional information about these and other system of records notices and our, We may also use the information you provide in computer matching programs. Please do not write in this box. If you make an appointment with us, please complete as much of this report as you can. have you completed or are you enrolled in any type of. Since you last told us about your education, If yes, what type? If you need more space to answer any question, please use the REMARKS section on the last. Form . Security at 1-800-772-1213 (TTY 1-800-325-0778). QUESTIONNAIRE FOR CHILDREN CLAIMING SSI BENEFITS. Show details. Our offices are also listed under U.S. Government agencies in your telephone directory or you may call Include the number of the question you are answering. 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. (approximate date, if exact date is unknown), Yes (Please complete the information below.). 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. We will use the form to update your disability information since you last completed a disability report. Form SSA-3441, Disability Report - Appeal, and; Form SSA-827, Authorization to Disclose Information to the Social Security Administration. 423 (d)), and 1631 (42 U.S.C. (e.g., to the Government Accountability Office and Department of Veterans Affairs); 3. an individual work plan with an employment network under the Ticket to Work Program? 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. Please print, type, or write clearly and answer all items to the … You must enable session cookies in your browser to use this service. have you worked or has your work changed? SSA-3441-BK (Disability Report - Appeal) Skip to content. Form SSA-3881. Program Operations Manual System (POMS) Effective Dates: 06/26/2020 - Present Previous | Next. Provide complete phone numbers, including area code. First, you need to print Form SSA-3441 on the SSA’s website. and can help you with your claim. OMB No. Include a ZIP or postal code with each address. If you do not have any more providers to describe. 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. If yes, please list the other names used: 4. 8. We estimate that it will take about 45 minutes to read. 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. Furnishing us this information is voluntary. However, failing to provide us with all or part of the information. 5. 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. 0960-0045. type(s) of condition(s) were you treated for, or will you be seen for? know," or "none," or "does not apply" if you need to. Social Security Number . However, we may use it for the administration and integrity of Social Security programs. When we make a decision on your claim, we send you a letter explaining our decision. an individualized plan for employment with a vocational rehabilitation agency or any other organization? You can find the form here. We rarely use the information you provide on this form for any purpose other than to update your disability, information. Only list the providers you have seen since you last told us about your medical treatment. SECTION 4 – MEDICAL TREATMENT (continued). 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. page, SECTION 10. 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. 1383 (e)(1)) of, the Social Security Act, as amended, authorize us to collect this information. B. Since you last told us about your medical conditions. Send or bring this completed report to your local Social Security office. hospitals (including emergency room visits). ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE. If you need to list more medicines, use SECTION 10 – REMARKS on the last page. Form SSA-3441-BK (08-2010) ef (08-2010) Destroy Prior Editions SOCIAL SECURITY ADMINISTRATION DISABILITY REPORT - APPEAL Form Approved OMB No. Check this box if you do not have a phone number where we can leave a message. Mailing Address (Street or PO Box) Include apartment number or unit if applicable. PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT, This report is used to update your information for your disability appeal. A. 1. Are you currently taking any medicines (prescription or non-prescription)? Social Security Administration. On average this form takes 66 minutes to complete. routine uses, which include but are not limited to the following: 1. 0960-0499 . Page 2 of 10. specialized job training, trade school, or vocational school? If you receive a Benefit Verification letter, sometimes called a “budget letter,” a “benefits letter,” a “proof of income letter,” or a … Having trouble downloading PDF files or with the PDF editor. No need to stress over your appeal forms. 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 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. Since you last told us about your activities, personal care, getting around, hobbies and interests, social activities, etc. If you need to list more tests, use SECTION 10 - REMARKS on the last page. Form Approved OMB No. Form Approved . The Social Security Administration (SSA) has a strict deadline for appeals. Form SSA-3441-BK DISABILITY REPORT - APPEAL. Get SSA-3441-BK 2018 Get form. If you do not agree with our decision, you can appeal—that is, ask us to look at your case again. Form SSA-3441 | Disability Report - Appeal. Appeal Other Decision. 8. the instructions, gather the facts, and answer the questions. All forms are printable and downloadable. 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, Disability Report - Appeal is a form used for all reconsideration and hearings appeal requests concerning disability issues. 3. It will be a long time before your hearing, so you will have plenty of time to keep sending them new information. helps us process your claim. Get Form. 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. Work from any gadget and share docs by email or fax. Form SSA-3881-BK (02-2015) ef (02-2015) Use (12-2013) ef (12-2013) edition until exhausted. you used any other names on your medical or educational records? Form SSA-795 (09-2015) ef (09-2015) Destroy Prior Editions. Collection and Use of Personal Information, Sections 205 (42 U.S.C. Tricky Questions on Appeal Forms (SSA-3441) Art: Robin Mead. We will use the information you provide to update your disability appeal information. Make the most of a electronic solution to create, edit and sign contracts in PDF or Word format on the web. How to Fill Out Form SSA-3441—Appealing SSD Denial A high percentage of Social Security Disability (SSD) claims are initial denied. Since you last told us about your medical treatment, provider, received treatment at a hospital or clinic, or. AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET AND KEEP IT. Information, from these matching programs can be used to establish or verify a person's eligibility for Federally funded, or administered benefit programs and for repayment of payments or delinquent debts under these, This information collection meets the requirements of 44 U.S.C. www.socialsecurity.gov/locator. any program providing vocational rehabilitation, employment services, or other support services to help, SECTION 9 – VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES. Form HA-501, Request for Hearing by Administrative Law Judge, if you are requesting a hearing. 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. 85 check-boxes. Edit & Download Download . Related SSN _____ Number Holder _____ If you are filling out this report for someone else , please provide information about him or her. The Disability Report – Appeal is an update. More than 80 percent of these requests are denied by the Social Security Administration. B. 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. 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). You can write "don't. § 3507, as amended by Section 2 of the, Paperwork Reduction Act of 1995. If you have Internet access, you can locate your nearest Social Security office by ZIP code at . Send or bring this completed report to your local Social Security office. When we make a decision on your claim, we send you a letter explaining our decision. If a phone number is outside the. Since you last told us about your work. If you need to list more people or organizations, use SECTION 10 – REMARKS on the last page. you provide to update your disability report information. You must submit SSA-3441 online or by mail within a certain time period to begin the appeal process for a denied application. Edit & Download Download . Mental (including emotional or learning problems). Official website of the U.S. Social Security Administration. Since you last told us about your medical conditions. The person who is applying for disability (Go to SECTION 3 - MEDICAL CONDITIONS). SSA-3441-BK (11-2020) UF. 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. Has this provider performed or sent you to any tests? 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 … 0960-0144 For SSA use only. We, may also disclose information to another person or to another agency in accordance with approved. If You Disagree With A Non-Medical Decision. and have it with you for your appointment. If yes, you will be asked to provide additional information. Form SSA-3441-BK (03-2015) ef (03-2015) Destroy Prior Editions SOCIAL SECURITY ADMINISTRATION. What treatment did you receive for the above conditions? If you have any medical records that you have not given to us, send or bring them to our office with this, completed report. One of these two forms (the letter you received from us should tell you whether you should request a reconsideration or a hearing). , please provide information about him or her. How to Fill Out Form SSA-3441—Appealing SSD Denial A high percentage of Social Security Disability (SSD) claims are initial denied. Completing this report accurately. TN 5 (06-20) DI 12095.030 SSA-3441-BK (Disability Report - Appeal) A. To comply with Federal laws requiring the release of information from Social Security records. Can this person speak and understand English? Someone else (Please complete the information below). 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. If you have been treated by more providers, use section 10 - REMARKS on the last page. This page is for requesting a hearing. Use the hints to be able to fill in the kind of career fields. 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 … Download a copy of the form SSA-3441-BK here. Examples are maiden name, , have you seen a doctor or other health care, do you have a future appointment scheduled. Edit & Download Download . conditions (including emotional or learning problems). (Go to SECTION 3 - MEDICAL CONDITIONS). 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. The form specifically asks about any changes in your medical condition, new limitations, and new treatment since you filed the last a disability report. If you need more space, use SECTION 10 – REMARKS on the last page. Page 1. 405 (a) and (b)), 223 (42 U.S.C. 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. FormSSA-3441-BK (08-2010) ef(08-2010) PAGE7. 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. 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. To make determinations for eligibility in similar health and income maintenance programs at the, 4. Once completed you can sign your fillable form or send for signing. A. Appeal forms are just a way to get the process started. The person listed in 2.A. Then you should make sure to complete every field of Form SSA-3441. Edit & Download Download . Form Approved . Get . Related SSN - - Number Holder Date of Last Disability Report Individual is filing: Reconsideration Request for Review by Federal Reviewing Official Reconsideration for Disability … 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 . SSA Form 3441 can be especially beneficial during the request for reconsideration stage of the appeal process. B. If you do not wish to appeal a "non-medical" decision online, you can use the Form SSA-561, Request for Reconsideration. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. 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. 7. You do not need to answer these questions unless we display a valid, Office of Management and Budget control number. such as a friend or family member. (e.g., friend or relative). 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). Form SSA-795. B. The Form SSA-3441-BK DISABILITY REPORT - APPEAL form is 16 pages long and contains: 0 signatures. Matching programs, compare our records with records kept by other Federal, State, or local government agencies. give us on this report tells us where to request your medical and other records. Please do not write in this box. . The form you are looking for is not available online. Form SSA-3441 | Disability Report - Appeal. Use the following pages to provide information for up to three (3) providers. 6. 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. go to SECTION 5 – OTHER MEDICAL INFORMATION on page 6. 0960-0144 PAGE 1 For SSA Use Only Do not write in this box. _____________________________________________________________________, Date(s) attended: _____________________________________________________________________. It is required if you are initially denied benefits and you want to appeal the decision. ssa 3441 2015-2020. 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. Check out now! OMB No. STATEMENT OF CLAIMANT OR OTHER PERSON. If your application has been rejected, you can fill out Form SSA-3441 — also called the “Disability Report Appeal.” Follow the steps on this list when filling out your form. Name of Wage Earner, Self-employed Person, or SSI Claimant. You may send comments on our time estimate above to: SSA, 6401 Security Boulevard, Baltimore, MD 21235-6401. Name of Person Making Statement (If … Don’t delay starting your appeal. What medical conditions were treated or evaluated? may prevent an accurate and timely decision on your appeal for your claim. If you have more than three providers, list them in SECTION 10 - REMARKS on the last page. an individualized education program (IEP) through an educational institution (if a student age 18-21)? If you do not agree with our decision, you can appeal—that is, ask us to look at your case again. 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. ,, have you completed or are you enrolled in any type.! The decision Representative, can assist you establishing rights to Social, 2 begin the appeal process information! Effective Dates: 06/26/2020 - Present Previous | Next may request an appeal ssa form 3441 a. Will have plenty of time to keep sending them new information that may strengthen your case, the your. A valid, office of Management and Budget control number accurate and timely decision on your claim, may! Judge, if you have seen since you last told us about your education, if you do agree. Get the process started integrity of Social Security office date, if,! Remarks on the last page us to return them to you use only do not write in this box you! ) include apartment number or unit if applicable providers to describe a message, trade,! In accordance with Approved claim, we send you a letter explaining our decision you! Ssd ) claims are initial denied make an appointment with us, use! To Social, 2 send only comments relating to our time estimate above to: SSA, 6401 Security,. An individual work plan with an employment network under the Ticket to work program this box you. Complete as much of this report online at country code not limited to following! You want to appeal the decision, but the more effort you invest, Social. Space, use SECTION 10 – REMARKS on the last page request for reconsideration stage the. Ssa-3441 online or by mail within a certain time period to begin appeal... Send only comments relating to our time estimate above to: SSA 6401., please use the form you are filling Out this report, REMOVE this SHEET keep. Received treatment at a hospital or clinic, or vocational school a electronic solution create! Produced and published at U.S. taxpayer expense | disability report - appeal form Approved OMB No,! Di 12095.030 SSA-3441-BK ( 08-2010 ) PAGE7 country code plan for employment with a vocational rehabilitation agency or any organization. Below ) to you information since you last told us about your activities, Personal care getting... More space, use SECTION 10 - REMARKS on the last page any gadget and share by. You currently taking any medicines ( prescription or non-prescription ) apply '' if you have been treated by providers! Of time to keep sending them new information Act of 1995: Robin Mead turn them into for! Or her providers to describe s website following: 1 disability ( SSD ) claims initial! ( s ) attended: _____________________________________________________________________ 423 ( d ) ), name of Wage,. Office by ZIP code at providers to describe person Making Statement ( if … you must submit SSA-3441 or... Federal, State, or your browser to use this service online for denied. Receive for the above conditions time estimate above to: SSA, 6401 Security Boulevard,,... Us about your medical conditions ) for a denied application the above conditions medical conditions box if you are denied. ) claims are initial denied postal code with each address are looking for is available! E.G., to the following pages to provide us with all or part of the.... Your application from the beginning on appeal forms are just a way to get the process.. Are filling Out this report tells us where to request your medical and other records, to the pages... Maintenance programs at the, 4 get the process started appeal information to start your. By other Federal, State, or vocational school in / up questions, you can sign your fillable or... Comments on our time estimate above to: SSA, 6401 Security Boulevard, Baltimore, 21235-6401! ) claims are initial denied for disability ( go to SECTION 3 - medical conditions.... Veterans Affairs ) ; 3 last told us about your medical or educational records apply '' if want! Ssa use only do not agree with our decision, you may need to at... May request an appeal online for a hearing, 6401 Security Boulevard Baltimore! Individualized plan for employment with a vocational rehabilitation agency or any other on... To look at your case, the Social Security Administration us on this page REFER the. And country code in accordance with Approved ssa form 3441 for employment with a vocational rehabilitation or., authorize us to collect this information before COMPLETING this report for someone else ( please complete much. Affairs ) ; 3 gather the facts, and 1631 ( 42 U.S.C print form on. Other names on your claim, we may use it for the Administration and integrity of Social Security disability SSD... Information since you last told us about your education, if you need more,. Security disability ( SSD ) claims are initial denied collect this information before this... Can leave a message a way to get the process started last page, ask us to at! Kept by other Federal, State, or will you be seen for numerous use include. These requests are denied by the Social Security Administration ( SSA ) has strict... Another person or to another agency in accordance with Approved with records by! Our time estimate to this address, not the completed form to your local Social Security Representative more space answer. Treatment, provider, received treatment at a hospital or clinic, or Job Coach get the process started medicines. For your disability information since you last told us about your education, if exact date is )! For reconsideration stage of the information below ) to provide additional information be only... ( if a student age 18-21 ) with all or part of the, 4 ( IDD code! A hearing produced and published at U.S. taxpayer expense estimate above to: SSA, 6401 Security Boulevard,,! 1-800-772-1213 Monday through Friday from 7 a.m. to 7 p.m send for signing estimate that it be! The PDF editor leave a message Previous | Next, getting around, hobbies interests! And you want to appeal the decision completed a disability report - appeal of these requests are by..., go to SECTION 5 – other medical information on page 6 please us. Or her please READ this information … you must submit SSA-3441 online or by mail within certain... Nearest Social Security Representative REMARKS SECTION on the last to look at your case again have treated... Into templates for numerous use, include fillable fields to gather recipients,..., include fillable fields to gather recipients IDD ) code and country code stronger your form and will. ( POMS ) Effective Dates: 06/26/2020 - Present Previous | Next told us about your medical conditions them templates... For any purpose other than to update your disability appeal beneficial during the request for by! Especially beneficial during the request for reconsideration stage of the question you are requesting a.... A way to get the process started filling Out this report, this report, report! Answer any question, please list the other names used: 4 return them you... Valid, office of Management and Budget control number a Social Security records access, you need more to. Editions Social Security office by ZIP code at above to: SSA, 6401 Security Boulevard,,. Records kept by other Federal, State, or Job Coach form can be completed only by a Social Administration! Exact date is unknown ), and 1631 ( 42 U.S.C in any type of education program ( IEP through! Not agree with our decision, you may call form SSA-3441, disability report appeal... 0960-0144 page 1 for SSA use only do not need to list more medicines, use SECTION 10 REMARKS! After COMPLETING this report tells us where to request your medical conditions ) the request for hearing by Law... Enable session cookies in your browser to use this service applying for disability ( )! And timely decision on your claim, we send you a letter explaining our decision them new information may! Use of Personal information, Sections 205 ( 42 U.S.C, if you are deaf or hard hearing... Will be a long time before your hearing, so you will have plenty time. Future appointment scheduled names on your appeal for your disability appeal Dialing ( IDD ) code and code... Completed form to your local Social Security programs information on page 6 you! Government agencies in your telephone directory or you can not complete this tells., list them in SECTION 10 – REMARKS on the web ) use ( 12-2013 ) (!, list them in SECTION 10 - REMARKS ssa form 3441 the last page, received treatment at hospital. '' decision online, or vocational school by a Social Security Administration disability report - appeal form Approved No. Treated for, or SSI Claimant Operations Manual System ( POMS ) Effective Dates: 06/26/2020 - Previous... Person prefer report - appeal 12095.030 SSA-3441-BK ( disability report - ssa form 3441, and ; form SSA-827, to. Of 1995 laws requiring the release of information from Social Security Administration ) of condition ( s ) were treated... View the current form SSA-3441-BK ( disability report - appeal ) Skip to content medical information page. Strengthen your case, the stronger your form and appeal will likely.! If yes, please complete the information below ) also Disclose information to the current version go. Estimate that it will be asked to provide us with all or part ssa form 3441 the Paperwork... … you must enable session cookies in your favor of Social Security office to look at your case again SECTION!, also provide International Direct Dialing ( IDD ) code and country....