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