A. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. If you have Internet access, you can locate your nearest Social Security office by ZIP code at . information, put and request legally-binding digital signatures. § 3507, as amended by Section 2 of the, Paperwork Reduction Act of 1995. 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. Mailing Address (Street or PO Box) Include apartment number or unit if applicable. B. No need to stress over your appeal forms. Our offices are also listed under U.S. Government agencies in your telephone directory or you may call Form SSA-3881-BK (02-2015) ef (02-2015) Use (12-2013) ef (12-2013) edition until exhausted. Since you last told us about your medical conditions. If a phone number is outside the. We will use the form to update your disability information since you last completed a disability report. 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. The Disability Report – Appeal is an update. SSA-3441-BK (Disability Report - Appeal) Skip to content. Please tell us if you want us to return them to you. Since you last told us about your medical treatment, provider, received treatment at a hospital or clinic, or. 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-BK (11-2020) UF. you provide to update your disability report information. _____________________________________________________________________, Date(s) attended: _____________________________________________________________________. 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. If you need to list more people or organizations, use SECTION 10 – REMARKS on the last page. Additional information about these and other system of records notices and our, We may also use the information you provide in computer matching programs. ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE. We will use the information. If you need more space, use SECTION 10 – REMARKS on the last page. ssa 3441. type(s) of condition(s) were you treated for, or will you be seen for? If you have more than three providers, list them in SECTION 10 - REMARKS on the last page. Form SSA-3441-BK, Disability Report - Appeal is a form used for all reconsideration and hearings appeal requests concerning disability issues. 5. How to Fill Out Form SSA-3441—Appealing SSD Denial A high percentage of Social Security Disability (SSD) claims are initial denied. If you make an appointment with us, please complete as much of this report as you can. B. Check out now! OMB No. 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 . What is SSA Form 3441? (Go to SECTION 3 - MEDICAL CONDITIONS). Since you last told us about your education, If yes, what type? We will use the information you provide to update your disability appeal information. Page 1. 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. and have it with you for your appointment. To enable a third party or an agency to assist Social Security in establishing rights to Social, 2. 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. Only list the providers you have seen since you last told us about your medical treatment. Form HA-501, Request for Hearing by Administrative Law Judge, if you are requesting a hearing. 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 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. You may request an appeal online for a "non-medical" decision. If you cannot complete this report, a Social Security representative, can assist you. 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. A. QUESTIONNAIRE FOR CHILDREN CLAIMING SSI BENEFITS. 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. 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). have you worked or has your work changed? ), Name of Counselor, Instructor, or Job Coach. 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 … The Social Security Administration (SSA) has a strict deadline for appeals. 8. any program providing vocational rehabilitation, employment services, or other support services to help, SECTION 9 – VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES. You can write "don't. When we make a decision on your claim, we send you a letter explaining our decision. Then you should make sure to complete every field of Form SSA-3441. When we make a decision on your claim, we send you a letter explaining our decision. If you receive a Benefit Verification letter, sometimes called a “budget letter,” a “benefits letter,” a “proof of income letter,” or a … If yes, you will be asked to provide additional information. We rarely use the information you provide on this form for any purpose other than to update your disability, information. Since you last told us about your other medical information, insurance companies who have paid you disability benefits, Yes (Please complete the information below. However, we may use it for the administration and integrity of Social Security programs. Since you last told us about your work. 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. All forms are printable and downloadable. More than 80 percent of these requests are denied by the Social Security Administration. 0960-0144 For SSA use only. ssa 3441. Appeal forms are just a way to get the process started. Form SSA-3441-BK DISABILITY REPORT - APPEAL. 1. Form Approved . DISABILITY REPORT – APPEAL Page 1. This website is produced and published at U.S. taxpayer expense. you used any other names on your medical or educational records? 8. Please do not write in this box. Appeal Other Decision. know," or "none," or "does not apply" if you need to. an individual work plan with an employment network under the Ticket to Work Program? Get Form. 7. What treatment did you receive for the above 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. The form you are looking for is not available online. 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 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. You can find the form here. 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. 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 required if you are initially denied benefits and you want to appeal the decision. 1383 (e)(1)) of, the Social Security Act, as amended, authorize us to collect this information. Page 2 of 10. Download a copy of the form SSA-3441-BK here. Having trouble downloading PDF files or with the PDF editor. Show details. B. Social Security Search Menu Languages Sign in / up. Since you last told us about your medical conditions. The Form SSA-3441-BK DISABILITY REPORT - APPEAL form is 16 pages long and contains: 0 signatures. 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. Form SSA-3441-BK (08-2010) ef (08-2010) Destroy Prior Editions SOCIAL SECURITY ADMINISTRATION DISABILITY REPORT - APPEAL Form Approved OMB No. STATEMENT OF CLAIMANT OR OTHER PERSON. You must submit the form before the SSA’s deadline, or you risk having to start over from the beginning with your application. 405 (a) and (b)), 223 (42 U.S.C. Link to the current form SSA-3441-BK To view the current version, go to SSA-3441–BK. Form SSA-3441 | Disability Report - Appeal. Please complete as much of this report as you can. Tricky Questions on Appeal Forms (SSA-3441) Art: Robin Mead. If you have been treated by more providers, use section 10 - REMARKS on the last page. 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. 6. Fillable Printable Form SSA-3881. 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. Please do not write in this box. 0960-0144 PAGE 1 For SSA Use Only Do not write in this box. Work from any gadget and share docs by email or fax. United States, also provide International Direct Dialing (IDD) code and country code. give us on this report tells us where to request your medical and other records. The form can be completed online, or you can complete the form by hand. Send or bring this completed report to your local Social Security office. 423 (d)), and 1631 (42 U.S.C. Many forms must be completed only by a Social Security Representative. Please print, type, or write clearly and answer all items to the … 0960-0045. If you do not agree with our decision, you can appeal—that is, ask us to look at your case again. However, failing to provide us with all or part of the information. Has this provider performed or sent you to any tests? ssa 3441 2015-2020. the instructions, gather the facts, and answer the questions. Form Approved OMB No. If you have any medical records that you have not given to us, send or bring them to our office with this, completed report. 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. Edit & Download Download . When we make a decision on your claim, we send you a letter explaining our decision. Provide complete phone numbers, including area code. We, may also disclose information to another person or to another agency in accordance with approved. 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. (e.g., friend or relative). 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. Edit & Download Download . Social Security Administration. (approximate date, if exact date is unknown), Yes (Please complete the information below.). hospitals (including emergency room visits). . 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 have new information that may strengthen your case, the information provide on Form 3441 may tip the scales in your favor. 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. 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