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