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