Form SSA-3441-BK Disability Report--Appeal

DISABILITY REPORT - APPEAL
SSA-3441-BK
PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT
This report is used to update your information for your disability appeal. Completing this report accurately
helps us process your claim. Please complete as much of this report as you can.
IF YOU NEED HELP
Please do not ask your health care provider to complete this report. You can get help from other people,
such as a friend or family member. If you cannot complete this report, a Social Security representative
can assist you. If you make an appointment with us, please complete as much of this report as you can
and have it with you for your appointment.
HOW TO COMPLETE THIS REPORT
If you have Internet access, you may be able to complete this report online at
www.ssa.gov/disability/appeal
If you complete this report on paper:

•
•

Print or write clearly.

•

Provide complete phone numbers, including area code. If a phone number is outside the
United States, also provide International Direct Dialing (IDD) code and country code.

•

If you cannot remember the names and addresses of your health care providers, you may be
able to get that information from the telephone book, Internet, medical bills, prescriptions, or
prescription medicine containers.

•

ANSWER EVERY QUESTION, unless this report indicates otherwise. You can write "don't
know," or "none," or "does not apply" if you need to.

•

If you need more space to answer any question, please use the REMARKS section on the last
page, SECTION 10. Include the number of the question you are answering.

Include a ZIP or postal code with each address.

YOUR MEDICAL RECORDS
If you have any medical records that you have not given to us, send or bring them to our office with this
completed report. Please tell us if you want us to return them to you. If you are having an interview in our
office, bring your medical records, your prescription medicine containers (if available), and this completed
report with you.
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS THAT YOU
DO NOT ALREADY HAVE. With your permission, we will request your records. The information that you
give us on this report tells us where to request your medical and other records.
HOW TO SUBMIT THIS REPORT
Send or bring this completed report to your local Social Security office. If you have Internet access, you
can locate your nearest Social Security office by zip code at www.socialsecurity.gov/locator. Our offices
are also listed under U.S. Government agencies in your telephone directory or you may call Social
Security at 1-800-772-1213 (TTY 1-800-325-0778).

Privacy Act Statement
Disability Report - Appeal
Collection and Use of Personal Information
Sections 205 (42 U.S.C. 405 (a) and (b)), 223 (42 U.S.C. 423 (d)), and 1631 (42 U.S.C. 1383 (e)(1)) of
the Social Security Act, as amended, authorize us to collect this information. We will use the information
you provide to update your disability report information.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information
may prevent an accurate and timely decision on your appeal for your claim.
We rarely use the information you provide on this form for any purpose other than to update your disability
information. However, we may use it for the administration and integrity of Social Security programs. We
may also disclose information to another person or to another agency in accordance with approved
routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social
Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security
records (e.g., to the Government Accountability Office and Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity of Social Security programs (e.g., to the U.S. Census Bureau and to private entities
under contract with us).
A complete list of when we may share your information with others, called routine uses, is available in our
Privacy Act Systems of Records Notices entitled, Claims Folder System (60-0089) and Electronic
Disability (60-0320). Additional information about these and other system of records notices and our
programs are available online at www.socialsecurity.gov or at your local Social Security office.
We may also use the information you provide in computer matching programs. Matching programs
compare our records with records kept by other Federal, State, or local government agencies. Information
from these matching programs can be used to establish or verify a person's eligibility for Federally funded
or administered benefit programs and for repayment of payments or delinquent debts under these
programs.

Paperwork Reduction Act
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by Section 2 of the
Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid
Office of Management and Budget control number. We estimate that it will take about 45 minutes to read
the instructions, gather the facts, and answer the questions.
You may send comments on our time estimate above to:
SSA, 6401 Security Boulevard, Baltimore, MD 21235-6401.
Send ONLY comments relating to our time estimate to this address, not the completed form.

AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET AND KEEP IT
FOR YOUR RECORDS.

Form Approved
OMB No. 0960-0144

SOCIAL SECURITY ADMINISTRATION

DISABILITY REPORT – APPEAL
For SSA use only. Please do not write in this box
Related SSN

Number Holder

If you are filling out this report for someone else, please provide information about him or her. When a question
refers to “you” or “your,” it refers to the person who is applying for disability benefits.
SECTION 1 – INFORMATION ABOUT THE DISABLED PERSON
1. A. Name (First, Middle, Last, Suffix)

1. B. Social Security Number

1. C. Daytime Phone Number, including area code (include IDD and country codes if outside the U.S. or Canada)
Check this box if you do not have a phone number where we can leave a message.
1. D. Alternate Phone Number – another number where we may reach you, if any

1. E. Email Address (Optional)

SECTION 2 – CONTACTS
Give the name of someone (other than your doctors) we can contact who knows about your medical conditions,
and can help you with your claim. (e.g., friend or relative)
2. A. Name (First, Middle, Last)

2. B. Relationship to Disabled
Person

2. C. Mailing Address (Street or PO Box), include apartment number or unit if applicable.

City

State/Province

ZIP/Postal Code

Country (if not U.S.)

2. D. Daytime Phone Number, including area code (include IDD and country codes if outside the U.S. or Canada)

2. E. Can this person speak and understand English?
Yes

No

If no, what language does the contact person prefer?
2. F. Who is completing this form?
The person who is applying for disability (Go to SECTION 3 - MEDICAL CONDITIONS).
The person listed in 2.A. (Go to SECTION 3 - MEDICAL CONDITIONS).
Someone else (Please complete the information below).
2. G. Name (First, Middle, Last)

2. H. Relationship to Disabled
Person

2. I. Mailing Address (Street or PO Box) Include apartment number or unit if applicable.

City

State/Province

ZIP/Postal Code

Country (if not U.S.)

2. J. Daytime Phone Number, including area code (include IDD and country codes if outside the U.S. or Canada)

Form SSA-3441-BK (03-2015) ef (03-2015)
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SECTION 3 – MEDICAL CONDITIONS
3. A. Since you last told us about your medical conditions, has there been any CHANGE (for better or worse)
in your physical or mental conditions?
Yes, approximate date change occurred:

No

If yes, please describe in detail:

3. B. Since you last told us about your medical conditions, do you have any NEW physical or mental
conditions?
Yes, approximate date of new conditions:

No

If yes, please describe in detail:

If you need more space, use SECTION 10 – REMARKS on the last page.

SECTION 4 – MEDICAL TREATMENT
4. A. Have you used any other names on your medical or educational records? Examples are maiden name,
other married name, or nickname.
No
Yes
If yes, please list the other names used:

4. B. Since you last told us about your medical treatment, have you seen a doctor or other health care
provider, received treatment at a hospital or clinic, or do you have a future appointment scheduled?
Yes

No (Go to SECTION 6 – MEDICINES)

4. C. What type(s) of condition(s) were you treated for, or will you be seen for?
Physical

Mental (including emotional or learning problems)

If you answered “Yes” to 4.B., please tell us who may have NEW medical records about any of your physical or
mental conditions (including emotional or learning problems).
Use the following pages to provide information for up to three (3) providers. Complete one page for each
provider. If you have more than three providers, list them in SECTION 10 - REMARKS on the last page.
Please include:
•
•
•
•
•

doctors' offices
hospitals (including emergency room visits)
clinics
mental health center
other health care facilities.
Only list the providers you have seen since you last told us about your medical treatment.

Form SSA-3441-BK (03-2015) ef (03-2015)

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Commented [KB1]: Add “previously described” after
“your”

SECTION 4 – MEDICAL TREATMENT (continued)
Provider 1
4. D. Name of facility or office

Name of health care provider who treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.

Patient ID# (if known)

Phone
Number
Address

City

State/Province

ZIP/Postal Code

Country (if not U.S.)

Dates of Treatment (approximate date, if exact date is unknown)
Office, Clinic or Outpatient visits at
this facility

Emergency Room visits at
this facility

Overnight hospital stays at
this facility

First Visit

Date

Date in

Date out

Last Visit

Date

Date in

Date out

Next scheduled appointment

Date

Date in

Date out

(if any)

Non
e
What medical conditions were treated or evaluated?

None

What treatment did you receive for the above conditions? (Do not list medicines or tests in this box.)

Has this provider performed or sent you to any tests? Please include tests you are scheduled to have in the
future.
Yes (Please complete the information below.)
No (Go to the next page.)
KIND OF TEST

DATES OF
TESTS

KIND OF TEST

Biopsy (list body part)

MRI/CT Scan (list body part)

Blood Test (not HIV)

Speech/Language Test

Breathing Test

Treadmill (exercise test)

Cardiac Catheterization

Vision Test

EEG (brain wave test)

X-ray (list body part)

EKG (heart test)
Hearing Test

Other (please describe)

HIV Test
IQ Testing

If you need to list more tests, use SECTION 10 - REMARKS on the last page.

If you do not have any more providers to describe,
Form SSA-3441-BK (03-2015) ef (03-2015)

Page 1

DATES OF
TESTS

go to SECTION 5 – OTHER MEDICAL INFORMATION on page 6.

Form SSA-3441-BK (03-2015) ef (03-2015)

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SECTION 4 – MEDICAL TREATMENT (continued)
Provider 2
Name of health care provider who treated you

4. D. Name of facility or
office

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone
Number

Patient ID# (if known)

Address

City

State/Province

ZIP/Postal Code

Country (if not U.S.)

Dates of Treatment (approximate date, if exact date is unknown)
Office, Clinic or Outpatient visits at
this facility

Emergency Room visits at
this facility

Overnight hospital stays at
this facility

First Visit

Date

Date in

Date out

Last Visit

Date

Date in

Date out

Next scheduled appointment

Date

Date in

Date out

(if any)

Non
e
What medical conditions were treated or evaluated?

None
Commented [KB2]: Add “new or updated” after “What”

What treatment did you receive for the above conditions? (Do not list medicines or tests in this box.)

Has this provider performed or sent you to any tests? Please include tests you are scheduled to have in the
future.
Yes (Please complete the information below.)
No (Go to the next page.)
KIND OF TEST

DATES OF
TESTS

KIND OF TEST

Biopsy (list body part)

MRI/CT Scan (list body part)

Blood Test (not HIV)

Speech/Language Test

Breathing Test

Treadmill (exercise test)

Cardiac Catheterization

Vision Test

EEG (brain wave test)

X-ray (list body part)

EKG (heart test)
Hearing Test

Other (please describe)

HIV Test
IQ Testing

If you need to list more tests, use SECTION 10 - REMARKS on the last page.
Form SSA-3441-BK (03-2015) ef (03-2015)

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DATES OF
TESTS

Commented [KB3]: Add “new or updated” after “What”

If youSECTION
do not have
any more TREATMENT
providers to describe,
4 – MEDICAL
(continued)
Provider 5
go to SECTION 5 – OTHER MEDICAL INFORMATION on page 6.

4. D. Name of facility or office

Form SSA-3441-BK (03-2015) ef (03-2015)

Name of health care provider who treated you

Page 5

SECTION 4 – MEDICAL TREATMENT (continued)
Provider 3
4. D. Name of facility or office

Name of health care provider who treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.

Patient ID# (if known)

Phone
Number
Address

City

State/Province

ZIP/Postal Code

Country (if not U.S.)

Dates of Treatment (approximate date, if exact date is unknown)
Office, Clinic or Outpatient visits at
this facility

Emergency Room visits at
this facility

Overnight hospital stays at
this facility

First Visit

Date

Date in

Date out

Last Visit

Date

Date in

Date out

Next scheduled appointment

Date

Date in

Date out

None

(if any)

None

What medical conditions were treated or evaluated?

Commented [KB4]: Add “new or updated” after “What”

What treatment did you receive for the above conditions? (Do not list medicines or tests in this box.)

Commented [KB5]: Add “new or updated” after “What”

Has this provider performed or sent you to any tests? Please include tests you are scheduled to have in the
future.
Yes (Please complete the information below.)
No (Go to the next page.)
KIND OF TEST

DATES OF
TESTS

KIND OF TEST

Biopsy (list body part)

MRI/CT Scan (list body part)

Blood Test (not HIV)

Speech/Language Test

Breathing Test

Treadmill (exercise test)

Cardiac Catheterization

Vision Test

EEG (brain wave test)

X-ray (list body part)

DATES OF
TESTS

EKG (heart test)
Hearing Test

Other (please describe)

HIV Test
IQ Testing

If you need to list more tests, use SECTION 10 - REMARKS on the last page.
Form SSA-3441-BK (03-2015) ef (03-2015)

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If you have been treated by more providers, use section 10 - REMARKS on the last page.

Form SSA-3441-BK (03-2015) ef (03-2015)

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SECTION
5 –4OTHER
MEDICAL
INFORMATION
SECTION
– MEDICAL
TREATMENT
(continued)
Provider 5
5. Since you last told us about your other medical information,
does anyone else have medical information
4. D.any
Name
of facility
or office
Name and
of health
careproblems)
provider who
treated
about
of your
physical
or mental conditions (including emotional
learning
or are
you you
scheduled to see anyone else?
This may include:
• workers’ compensation
• vocational rehabilitation services
• insurance companies who have paid you disability benefits
• prisons and correctional facilities
• attorneys
• social service agencies
• welfare agencies
• school/education records
Yes (Please complete the information below.)
No (Go to SECTION 6 – MEDICINES)
Name of Organization
Claim or ID Number (if any)
Address
City

State/Province ZIP/Postal Code

Name of Contact Person

Date of First Contact

Country (if not U.S.)

Phone Number

Date of Last Contact

Date of Next Contact (if any)

Reasons for Contacts

If you need to list more people or organizations, use SECTION 10 – REMARKS on the last page.

SECTION 6 – MEDICINES
6. Are you currently taking any medicines (prescription or non-prescription)?
Yes (Please complete the information below. You may need to look at your medicine containers.)
No (Go to SECTION 7 – ACTIVITIES)
NAME OF MEDICINE

IF PRESCRIBED,
NAME OF DOCTOR

REASON FOR MEDICINE

SIDE EFFECTS
YOU HAVE

If you need to list more medicines, use SECTION 10 – REMARKS on the last page.
Form SSA-3441-BK (03-2015) ef (03-2015)

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SECTION 7 - ACTIVITIES
7. Since you last told us about your activities, has there been any change (for better or worse) in your daily
activities due to your physical or mental conditions? (Examples of daily activities are household tasks,
personal care, getting around, hobbies and interests, social activities, etc.)
Yes

No

If yes, please describe in detail:

If you need more space, use SECTION 10 – REMARKS on the last page.
SECTION 8 – WORK AND EDUCATION
8. A. Since you last told us about your work, have you worked or has your work changed?
Yes
No
If yes, you will be asked to provide additional information.
8. B. Since you last told us about your education, have you completed or are you enrolled in any type of
specialized job training, trade school, or vocational school?
Yes

No

If yes, what type?
Date(s) attended:

If you need more space, use SECTION 10 – REMARKS on the last page.
SECTION 9 – VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES
9. Since you last told us about your vocational rehabilitation, have you participated, or are you participating in:
•
•
•
•
•

an individual work plan with an employment network under the Ticket to Work Program?
an individualized plan for employment with a vocational rehabilitation agency or any other organization?
a Plan to Achieve Self-Support (PASS)?
an individualized education program (IEP) through an educational institution (if a student age 18-21)?
any program providing vocational rehabilitation, employment services, or other support services to help
you go to work?

Yes (Please complete the information below.)
No (Go to SECTION 10 – REMARKS)
Name of Organization or School

Name of Counselor, Instructor, or Job Coach

Phone
Number

Address

City

State/Province

ZIP/Postal Code

Country (if not U.S.)

Date when you started participating in the plan or program:

If you need more space, use SECTION 10 – REMARKS on the last page.
Form SSA-3441-BK (03-2015) ef (03-2015)

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Commented [KB6]: Add “previously described” before
“daily”

SECTION 10 – REMARKS
Use this space to provide any information you could not show in earlier sections of this form or any additional
information you feel we should know about. Please be sure to include the number of the question you are answering
(For example, 3A, 4D, etc.).

Date Report Completed MM/DD/YYYY:
Form SSA-3441-BK (03-2015) ef (03-2015)

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