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