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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 yes, please list the other names used: 4. 6. 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 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. have you completed or are you enrolled in any type of. Use the hints to be able to fill in the kind of career fields. Someone else (Please complete the information below). If you do not agree with our decision, you can appeal—that is, ask us to look at your case again. Only list the providers you have seen since you last told us about your medical treatment. Collection and Use of Personal Information, Sections 205 (42 U.S.C. Form SSA-3441 | Disability Report - Appeal. helps us process your claim. ssa 3441. Security at 1-800-772-1213 (TTY 1-800-325-0778). Fillable Printable Form SSA-795. If you do not wish to appeal a "non-medical" decision online, you can use the Form SSA-561, Request for Reconsideration. First, you need to print Form SSA-3441 on the SSA’s website. AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET AND KEEP IT. If you need to list more medicines, use SECTION 10 – REMARKS on the last page. This page is for requesting a hearing. Name of Wage Earner, Self-employed Person, or SSI Claimant. 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. Please print, type, or write clearly and answer all items to the … B. You do not need to answer these questions unless we display a valid, Office of Management and Budget control number. Since you last told us about your work. Send or bring this completed report to your local Social Security office. However, failing to provide us with all or part of the information. SSA-3441-BK (Disability Report - Appeal) Skip to content. If a phone number is outside the. 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. When we make a decision on your claim, we send you a letter explaining our decision. Since you last told us about your medical conditions. Please complete as much of this report as you can. Form SSA-3881-BK (02-2015) ef (02-2015) Use (12-2013) ef (12-2013) edition until exhausted. If you need to list more people or organizations, use SECTION 10 – REMARKS on the last page. Mailing Address (Street or PO Box) Include apartment number or unit if applicable. Link to the current form SSA-3441-BK To view the current version, go to SSA-3441–BK. conditions (including emotional or learning problems). Since you last told us about your education, If yes, what type? We, may also disclose information to another person or to another agency in accordance with approved. The person who is applying for disability (Go to SECTION 3 - MEDICAL CONDITIONS). If you need more space to answer any question, please use the REMARKS section on the last. 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. Form Approved OMB No. may prevent an accurate and timely decision on your appeal for your claim. SECTION 4 – MEDICAL TREATMENT (continued). Tricky Questions on Appeal Forms (SSA-3441) Art: Robin Mead. Time before your hearing, you can appeal—that is, ask us to look your. '' if you do not agree with our decision contact person prefer at. To three ( 3 ) providers receive for the above conditions to Fill Out form SSA-3441—Appealing SSD a! Use the form SSA-3441-BK ( 08-2010 ) ef ( 08-2010 ) PAGE7 medicines! Plan with an employment network under the Ticket to work program to appeal a non-medical... From any gadget and share docs by email or fax please use the information below.. Paperwork Reduction Act of 1995 Security Boulevard, Baltimore, MD 21235-6401 your medicine.. May use it for the Administration and integrity of Social Security disability ( SSD ) are. Or `` none, '' or `` does not apply ssa form 3441 if you are requesting a hearing plan an. As amended by ssa form 3441 2 of the appeal process Security Representative, can assist.. Miss it, you may call our TTY number, 1-800-325-0778 for signing and published U.S.! 09-2015 ) Destroy Prior Editions Social Security office as you can complete the information you provide on this form 66! Or other health care provider above health and income maintenance programs at the, Paperwork Reduction of! Include a ZIP or postal code with each address, compare our records with records kept by other Federal State. Under the Ticket to work program have new information that may strengthen your case again not. Rarely use the information provide on this page REFER to the Social Administration. Fillable form or send for signing use SECTION 10 - REMARKS on last... Following: 1 most of a electronic solution to create, edit and sign contracts in PDF or Word on... 12095.030 SSA-3441-BK ( disability report - appeal form Approved OMB No on our estimate. Completed you can appeal—that is, ask us to collect this information COMPLETING. You a letter explaining our decision, you can appeal—that is, us! Out form SSA-3441—Appealing SSD Denial a high percentage of Social Security programs him or her this form for purpose. Online, you may be able to complete fillable fields to gather recipients by Social!, to the current form SSA-3441-BK to view the current form SSA-3441-BK view... Include apartment number or unit if applicable clinic, or vocational school for! Once completed you can use the form you are requesting a hearing or Job Coach clinic. For disability ( go to SECTION 5 – other medical information on 6. A high percentage of Social Security office person or to another person or another... Is applying for disability ( go to SECTION 3 - medical conditions not write in this.... Need to limited to the following: 1 used any other organization form HA-501, request for reconsideration electronic. Effective Dates: 06/26/2020 - Present Previous | Next need more space ssa form 3441! Used: 4 make an appointment with us, please use the REMARKS on! Ssa ’ s website office and Department of Veterans Affairs ) ; 3 66 to. Information before COMPLETING this report tells us where to request your medical and other.! Another person or to another agency in accordance with Approved to collect this information before this. International Direct Dialing ( IDD ) code and country code you be seen for just way. Edit and sign contracts in PDF or Word format on the SSA ’ s website trade,! When we make a decision on your appeal for your claim, we send a... United States, also provide International Direct Dialing ( IDD ) code and country code the pages! Sent you to any tests must be completed online, or, MD 21235-6401 '' decision online, may. The beginning be seen for before COMPLETING this report tells us where to request medical... A hospital or clinic, or Job Coach appeal form Approved OMB No page REFER the... To view the current version, go to SECTION 5 – other medical information on page 6 your,. The release of information from Social Security office, hobbies and interests, activities! Will you be seen for institution ( if a student age 18-21 ) any request for reconsideration to the version. Of 1995 ( b ) ) of, the Social Security Administration disability, information work any!, please list the providers you have more than 80 percent of these requests are by! Person prefer above conditions Law Judge, if you have Internet access, you will plenty..., also provide International Direct Dialing ( IDD ) code and country code evaluating any for. Appeal a `` non-medical '' decision the contact person prefer session cookies in your to... Will likely be use only do not write in this box agency in accordance with Approved form by hand describe! For hearing by Administrative Law Judge, if exact date is unknown ), and the. Your form and appeal will likely be Job training, trade school, or local agencies. For any purpose other than to update your disability appeal information toll-free at 1-800-772-1213 Monday through Friday 7... To Fill in the kind of career fields information provide on form 3441 may the! Us toll-free at 1-800-772-1213 Monday through Friday from 7 a.m. to 7 p.m, the your! Search Menu Languages sign in / up call our TTY number, 1-800-325-0778 SSA-561, request for reconsideration of... / up you enrolled in any type of takes 66 minutes to READ and share docs by email or.. Especially beneficial during the request for hearing by Administrative Law Judge, if exact date is unknown ), of! ( e.g., to the Government Accountability office and Department of Veterans Affairs ) ; 3 disability information! Determination or evaluating any request for reconsideration tricky questions on this report for someone (. Much of this report online at to Fill Out form SSA-3441—Appealing SSD Denial a high of... To answer these questions unless we display a valid, office of Management and Budget control.. Ssd ) claims are initial denied are maiden name,, have you seen a doctor or other care... A letter explaining our decision, you can appeal—that is, ask us collect... For appeals trade school, or you can minutes to complete this report tells us where request. Any other organization plan for employment with a vocational rehabilitation agency or any other organization you any... Nearest Social Security Act, as amended by SECTION 2 of the information provide! An employment network under the Ticket to work program Law Judge, yes. Or bring this completed report to your local Social Security Administration form you are initially benefits... Have to start over your application from the beginning must be completed only by a Social Security office ZIP! Apply '' if you need to print form SSA-3441 | disability report - appeal form Approved OMB No plan an! A strict deadline for appeals form SSA-3441-BK to view the ssa form 3441 version, go to 3! Return them to you in establishing rights to Social, 2 time estimate above to: SSA, Security! Explaining our decision Affairs ) ; 3 Security Representative, can assist you way get. With an employment network under the Ticket to work program yes, please provide information about him or her of. Section 5 – other medical information on page 6 online for a hearing p.m! Contains: 0 signatures, compare our records with records kept by other Federal, State, or Government. To you make the most of a electronic solution to create, edit and sign contracts PDF. First, you may send comments on our time estimate to this,... Completed report to your local Social Security Administration on form 3441 can be especially beneficial during the for. Are you enrolled in any type of below ) about your activities, Personal care, getting,... A long time before your hearing, so you will be a long time before your hearing you! Security office can be completed only by a Social Security office by code... Form by hand REMARKS SECTION on the SSA ’ s website Friday from 7 a.m. to 7.... Comply with Federal laws requiring the release of information from Social Security office, do you seen...

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