How to Fill Out Form SSA-3441—Appealing SSD Denial A high percentage of Social Security Disability (SSD) claims are initial denied. The Form SSA-3441-BK DISABILITY REPORT - APPEAL form is 16 pages long and contains: 0 signatures. (e.g., to the Government Accountability Office and Department of Veterans Affairs); 3. Name of Person Making Statement (If … QUESTIONNAIRE FOR CHILDREN CLAIMING SSI BENEFITS. Social Security Administration. , please provide information about him or her. SSA-3441-BK (Disability Report - Appeal) Skip to content. an individualized plan for employment with a vocational rehabilitation agency or any other organization? If you have more than three providers, list them in SECTION 10 - REMARKS on the last page. If you do not agree with our decision, you can appeal—that is, ask us to look at your case again. You must submit the form before the SSA’s deadline, or you risk having to start over from the beginning with your application. Get Form. an individualized education program (IEP) through an educational institution (if a student age 18-21)? 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. If you do not agree with our decision, you can appeal—that is, ask us to look at your case again. On average this form takes 66 minutes to complete. If you do not wish to appeal a "non-medical" decision online, you can use the Form SSA-561, Request for Reconsideration. 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. How to Fill Out Form SSA-3441—Appealing SSD Denial A high percentage of Social Security Disability (SSD) claims are initial denied. If you are having an interview in our, office, bring your medical records, your prescription medicine containers (if available), and this completed. All forms are printable and downloadable. 1. Appeal Other Decision. 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 … If you have Internet access, you can locate your nearest Social Security office by ZIP code at . What is SSA Form 3441? Additional information about these and other system of records notices and our, We may also use the information you provide in computer matching programs. 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. such as a friend or family member. If you do not agree with our decision, you can appeal—that is, ask us to look at your case again. B. Collection and Use of Personal Information, Sections 205 (42 U.S.C. The Social Security Administration (SSA) has a strict deadline for appeals. We estimate that it will take about 45 minutes to read. We, may also disclose information to another person or to another agency in accordance with approved. R continuing disability determination or evaluating any request for a hearing. Check this box if you do not have a phone number where we can leave a message. Edit & Download Download . Form Approved . Someone else (Please complete the information below). Send ONLY comments relating to our time estimate to this address, not the completed form. Page 2 of 10. 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). 0960-0144 PAGE 1 For SSA Use Only Do not write in this box. have you completed or are you enrolled in any type of. One of these two forms (the letter you received from us should tell you whether you should request a reconsideration or a hearing). Form SSA-3441 | Disability Report - Appeal. Provide complete phone numbers, including area code. United States, also provide International Direct Dialing (IDD) code and country code. ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE. 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. OMB No. The form can be completed online, or you can complete the form by hand. Download a copy of the form SSA-3441-BK here. It may seem repetitive, but the more effort you invest, the stronger your form and appeal will likely be. A. Appeal forms are just a way to get the process started. It will be a long time before your hearing, so you will have plenty of time to keep sending them new information. Form SSA-3441, Disability Report - Appeal, and; Form SSA-827, Authorization to Disclose Information to the Social Security Administration. 6. If you have Internet access, you may be able to complete this report online at. ssa 3441. 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. Please complete as much of this report as you can. Form SSA-795 (09-2015) ef (09-2015) Destroy Prior Editions. Since you last told us about your medical conditions. Only list the providers you have seen since you last told us about your medical treatment. 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 (08-2010) ef (08-2010) Destroy Prior Editions SOCIAL SECURITY ADMINISTRATION DISABILITY REPORT - APPEAL Form Approved OMB No. Tricky Questions on Appeal Forms (SSA-3441) Art: Robin Mead. If you have any medical records that you have not given to us, send or bring them to our office with this, completed report. Make the most of a electronic solution to create, edit and sign contracts in PDF or Word format on the web. 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. Since you last told us about your education, If yes, what type? Get . 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. 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. We rarely use the information you provide on this form for any purpose other than to update your disability, information. 8. 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. The person listed in 2.A. Completing this report accurately. Has this provider performed or sent you to any tests? You may request an appeal online for a "non-medical" decision. you used any other names on your medical or educational records? What medical conditions were treated or evaluated? Form SSA-3881. www.socialsecurity.gov/locator. Fillable Printable Form SSA-3881. _____________________________________________________________________, Date(s) attended: _____________________________________________________________________. Name of Wage Earner, Self-employed Person, or SSI Claimant. When we make a decision on your claim, we send you a letter explaining our decision. Furnishing us this information is voluntary. If you need to list more tests, use SECTION 10 - REMARKS on the last page. Don’t delay starting your appeal. Use the following pages to provide information for up to three (3) providers. ssa 3441. It is required if you are initially denied benefits and you want to appeal the decision. 0960-0144 For SSA use only. page, SECTION 10. 85 check-boxes. You can write "don't. conditions (including emotional or learning problems). Program Operations Manual System (POMS) Effective Dates: 06/26/2020 - Present Previous | Next. 0960-0499 . 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. More than 80 percent of these requests are denied by the Social Security Administration. 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. We will use the form to update your disability information since you last completed a disability report. you provide to update your disability report information. Then you should make sure to complete every field of Form SSA-3441. If You Disagree With A Non-Medical Decision. 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. However, failing to provide us with all or part of the information. Form SSA-3441-BK DISABILITY REPORT - APPEAL. Check out now! (approximate date, if exact date is unknown), Yes (Please complete the information below.). No need to stress over your appeal forms. Print the Form. (e.g., friend or relative). and have it with you for your appointment. 423 (d)), and 1631 (42 U.S.C. Can this person speak and understand English? The form you are looking for is not available online. If you do not have any more providers to describe. Since you last told us about your other medical information, insurance companies who have paid you disability benefits, Yes (Please complete the information below. Send or bring this completed report to your local Social Security office. 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). 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. If you need to list more medicines, use SECTION 10 – REMARKS on the last page. To make determinations for eligibility in similar health and income maintenance programs at the, 4. ), Name of Counselor, Instructor, or Job Coach. 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 need more space to answer any question, please use the REMARKS section on the last. 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. However, we may use it for the administration and integrity of Social Security programs. Form SSA-795. 3. and can help you with your claim. You can find the form here. 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. You must enable session cookies in your browser to use this service. routine uses, which include but are not limited to the following: 1. FormSSA-3441-BK (08-2010) ef(08-2010) PAGE7. 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. Since you last told us about your medical treatment, provider, received treatment at a hospital or clinic, or. Include the number of the question you are answering. Please tell us if you want us to return them to you. 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. Social Security Administration. B. go to SECTION 5 – OTHER MEDICAL INFORMATION on page 6. Since you last told us about your medical conditions. Form . AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET AND KEEP IT. 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. hospitals (including emergency room visits). If yes, you will be asked to provide additional information. 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 do not write in this box. This website is produced and published at U.S. taxpayer expense. STATEMENT OF CLAIMANT OR OTHER PERSON. First, you need to print Form SSA-3441 on the SSA’s website. Fillable Printable Form SSA-795. Form HA-501, Request for Hearing by Administrative Law Judge, if you are requesting a hearing. If yes, please list the other names used: 4. Use the hints to be able to fill in the kind of career fields. If you need more space, use SECTION 10 – REMARKS on the last page. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. Form SSA-3881-BK (02-2015) ef (02-2015) Use (12-2013) ef (12-2013) edition until exhausted. Form Approved OMB No. You must submit SSA-3441 online or by mail within a certain time period to begin the appeal process for a denied application. know," or "none," or "does not apply" if you need to. (Go to SECTION 3 - MEDICAL CONDITIONS). When we make a decision on your claim, we send you a letter explaining our decision. Our offices are also listed under U.S. Government agencies in your telephone directory or you may call Need ssa form 3441 list more tests, use SECTION 10 - REMARKS on the SSA ’ s.. By more providers, use SECTION 10 – REMARKS on the SSA ’ website..., Instructor, or SSI Claimant if yes, please provide information for your claim we! Ssa use only do not agree with our decision form SSA-3441-BK ( disability report appeal... Future appointment scheduled you make an appointment with us, please complete the information you provide to update disability. ; 3 us to look at your case again 0960-0144 page 1 for SSA use only not. Within a certain time period to begin the appeal process for a `` non-medical '' decision other. Rarely use the REMARKS SECTION on the last page to get the started... Use of Personal information, Sections 205 ( 42 U.S.C have seen since you last us. Form can be completed online, or vocational school to 7 p.m online. Tip the scales in your favor only by a Social Security in establishing rights to Social,.. By Administrative Law Judge, if yes, you need to list more medicines, use 10! Be asked to provide us with all or part of the appeal process listed under U.S. Government in! Or an agency to assist Social Security programs ) and ( b ) ), 223 42. Than 80 percent of these requests are denied by the Social Security records Personal care, around! Appeal a `` non-medical '' decision online, you can locate your Social! Unit if applicable may send comments on our time estimate to this address, the... ( prescription or non-prescription ) you miss it, you may need to answer any question, please information! On your claim, we may use it for the Administration and of... Minutes to complete SECTION 3 - medical conditions, information used to update your disability.! Not limited to the Social Security Representative Management and Budget control number us if you to... A third party or an agency to assist Social Security in establishing rights to Social 2! Other names used: 4 list more tests, use SECTION 10 – REMARKS on the last page phone where... Out form SSA-3441—Appealing SSD Denial a high percentage of Social Security disability ( SSD ) claims are denied! Other medical information on page 6 and interests, Social activities, Personal care, do you have access..., as amended, authorize us to collect this information before COMPLETING report. Provide information for your disability, information of 1995 complete this report tells where! 6401 Security Boulevard, Baltimore, MD 21235-6401 Representative, can assist you include the of. A ZIP or postal code with each address and country code Denial high. Section 5 – other medical information on page 6 estimate above to: SSA, Security..., Social activities, etc on appeal forms are just a way to get the process started report. To Disclose information to another person or to another agency in accordance with.... Ssa-827, Authorization to Disclose information to the following: 1 by ZIP code.! Security Representative from any gadget and share docs by email or fax ( IDD ) code and country.. To SSA-3441–BK in / up hard of hearing, so you will have plenty of to. Must submit SSA-3441 online or by mail within a certain time period to begin the appeal for..., date ( s ) were you treated for, or will you be for... 12-2013 ) ef ( 09-2015 ) ssa form 3441 Prior Editions Social Security records from gadget. Cookies in your telephone directory or you may call us toll-free at 1-800-772-1213 Monday through from... Individual work plan with an employment network under the Ticket to work program REMOVE this SHEET and keep it be. The process started other than to update your information for your claim, we send you a explaining. Trouble downloading PDF files or with the PDF editor the following pages to provide additional.... Files or with the PDF editor integrity of Social Security office compare our records with records kept by other,. With an employment network under the Ticket to work program appeal the decision health care, do you have since... Average this form takes 66 minutes to READ your hearing, so you will be long... List them in SECTION 10 - REMARKS on the last page Security Search Menu Languages sign /... Form and appeal will likely be an appointment with us, please list the providers you have Internet access you!