Fillable Printable Disability Report - Appeal
Fillable Printable Disability Report - Appeal
Disability Report - Appeal
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).
Privacy Act Statement
Disability Report - Appeal
Collection and Use of Personal Information
Sections 205 (42 U.S.C. 405 (a) and (b)), 223 (42 U.S.C. 423 (d)), and 1631 (42 U.S.C. 1383 (e)(1)) of
the Social Security Act, as amended, authorize us to collect this information. We will use the information
you provide to update your disability report information.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information
may prevent an accurate and timely decision on your appeal for your claim.
We rarely use the information you provide on this form for any purpose other than to update your disability
information. However, we may use it for the administration and integrity of Social Security programs. We
may also disclose information to another person or to another agency in accordance with approved
routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social
Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; and
4. 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
under contract with us).
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). Additional information about these and other system of records notices and our
programs are available online at www.socialsecurity.gov or at your local Social Security office.
We may also use the information you provide in computer matching programs. Matching programs
compare our records with records kept by other Federal, State, or local government agencies. 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
programs.
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.
Form SSA-3441-BK (03-2015) ef (03-2015)
Destroy Prior Editions
SOCIAL SECURITY ADMINISTRATION
Form Approved
OMB No. 0960-0144
DISABILITY REPORT – APPEAL
Page 1
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)
Page 2
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 physical or mental conditions?
□ Yes, approximate date change occurred: □ No
If yes, please describe in detail:
3. B. Since you last told us about your medical conditions, do you have any NEW physical or mental
conditions?
□ Yes, approximate date of new 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 (03-2015) ef (03-2015)
Form SSA-3441-BK (03-2015) ef (03-2015)
Page 3
SECTION 4 – MEDICAL TREATMENT (continued)
Provider 1
go to SECTION 5 – OTHER MEDICAL INFORMATION on page 6.
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.
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
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 __________________
o None
Overnight hospital stays at
this facility
Date in _____ Date out _____
Date in _____ Date out _____
Date in _____ Date out _____
o None
What medical conditions were treated or evaluated?
What treatment did you receive for the above conditions? (Do not list medicines or tests in this box.)
City
State/Province ZIP/Postal Code
Country (if not U.S.)
Dates of Treatment (approximate date, if exact date is unknown)
□ 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
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.)
□ 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
Form SSA-3441-BK (03-2015) ef (03-2015)
Page 4
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
go to SECTION 5 – OTHER MEDICAL INFORMATION on page 6.
If you do not have any more providers to describe,
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 __________________
o None
Overnight hospital stays at
this facility
Date in _____ Date out _____
Date in _____ Date out _____
Date in _____ Date out _____
o None
What medical conditions were treated or evaluated?
What treatment did you receive for the above conditions? (Do not list medicines or tests in this box.)
City
State/Province ZIP/Postal Code
Country (if not U.S.)
Dates of Treatment (approximate date, if exact date is unknown)
If you need to list more tests, use SECTION 10 - REMARKS on the last 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
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.)
□ 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
Form SSA-3441-BK (03-2015) ef (03-2015)
Page 5
SECTION 4 – MEDICAL TREATMENT (continued)
Provider 3
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.
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
□ Biopsy (list body part)
□ X-ray (list body part)
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 __________________
o None
Overnight hospital stays at
this facility
Date in _____ Date out _____
Date in _____ Date out _____
Date in _____ Date out _____
o None
What medical conditions were treated or evaluated?
What treatment did you receive for the above conditions? (Do not list medicines or tests in this box.)
City
State/Province ZIP/Postal Code
Country (if not U.S.)
Dates of Treatment (approximate date, if exact date is unknown)
□ MRI/CT Scan (list body part)
___________________
□ EKG (heart test)
□ Other (please describe)
__________________
□ Hearing Test
DATES OF
TESTS
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.)
□ 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
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)
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)
SECTION 5 – OTHER MEDICAL INFORMATION
NAME OF MEDICINE
IF PRESCRIBED,
NAME OF DOCTOR
REASON FOR MEDICINE
SIDE EFFECTS
YOU HAVE
No (Go to SECTION 7 – ACTIVITIES)
□
□
Yes (Please complete the information below. You may need to look at your medicine containers.)
6. Are you currently taking any medicines (prescription or non-prescription)?
Reasons for Contacts
If you need to list more people or organizations, use SECTION 10 – REMARKS on the last page.
SECTION 6 – MEDICINES
If you need to list more medicines, use SECTION 10 – REMARKS on the last page.
Form SSA-3441-BK (03-2015) ef (03-2015)
Page 6
If you need more space, use SECTION 10 – REMARKS on the last page.
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: _____________________________________________________________________
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)
If you need more space, use SECTION 10 – REMARKS on the last page.
Form SSA-3441-BK (03-2015) ef (03-2015)
Page 7
SECTION 8 – WORK AND EDUCATION
SECTION 9 – VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES
SECTION 7 - ACTIVITIES
7. Since you last told us about your activities, has there been any change (for better or worse) in your 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
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
If yes, please describe in detail:
Phone Number
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. Please be sure to include the number of the question you are answering
(For example, 3A, 4D, etc.).
Date Report Completed MM/DD/YYYY:
SECTION 10 – REMARKS
