Form SSA-3441-BK Disability Report - Appeal

What Is Form SSA-3441?

Form SSA-3441-BK, Disability Report - Appeal is a form used for all reconsideration and hearings appeal requests concerning disability issues. It is required if you are initially denied benefits and you want to appeal the decision. Its purpose is to collect information about the claimant's impairment, for example, if there is any change for better or worse in the impairment and if there is any additional or new impairment. Completing the disability report appeal helps the Social Security Administration (SSA) process your claim.

You must complete this form to keep your claim active if you receive a notice from the SSA that says you have been found ineligible for benefits. The SSA notice tells you the reason for the denial, describes the process for filing your request to get a reconsideration or to start an appeal process. It also informs you of the deadline for submitting this request. This deadline is essential to keep your claim open and active.

The latest version of the SSA-3441 was released by the SSA in April 2018 with all previous editions obsolete. An SSA-3441-BK fillable form can be downloaded below.

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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.
Include a ZIP or postal code with each address.
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.
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).
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.
Include a ZIP or postal code with each address.
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.
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(a), 223(d), and 1631(e) of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from reconsidering and reviewing your initial or continuing disability
determination or evaluating any request for a hearing.
We will use the information you provide to update your disability appeal information. The information we
collect also assists the State DDSs and administrative law judges in preparing for the appeals and
hearings, and issuing a determination or decision on an individual’s entitlement (initial or continuing) to
disability benefits.
We may also share your information for the following purposes, called routine uses:
1. To State audit agencies for auditing State supplementation payments and Medicaid
eligibility considerations;
2. To third party contacts where necessary to establish or verify information provided by
representative payees or payee applicants; and
3. To Federal, State or local agencies for administering cash or non-cash income
maintenance or health maintenance programs.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person’s eligibility for Federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORNs)
60-0089, entitled Claims Folders Systems; 60-0090, entitled Master Beneficiary Record; 60-0320, entitled
Electronic Disability; and 60-0103, entitled Supplemental Security Income Record and Special Veterans
Benefits. Additional information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.
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 SSA-3441-BK (04-2018) UF
Discontinue Prior Editions
Page 1 of 8
SOCIAL SECURITY ADMINISTRATION
OMB No. 0960-0144
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 (04-2018) UF
Page 2 of 8
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 (04-2018) UF
Page 3 of 8
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.
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
Emergency Room visits at
Overnight hospital stays at
this facility
this facility
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) ___________________
None
None
What medical conditions were treated or evaluated?
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.)
DATES OF
DATES OF
KIND OF TEST
KIND OF TEST
TESTS
TESTS
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,
go to SECTION 5 – OTHER MEDICAL INFORMATION on page 6.

Download Form SSA-3441-BK Disability Report - Appeal

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Disability Report Appeal

Form SSA-3441-BK - also known as Form SSA-3441 - is a critical part of moving forward with your Social Security Disability (SSD) claim. It allows the applicant to update the information provided in the initial claim that was denied for some reason. Social security appeal form was designed to allow the SSA to receive an update of what has transpired since the last time they have prepared a disability report.

The report's objective is to let the SSA determine what medical providers and new physicians have treated you, what treatment has been undertaken exactly, what medical tests were done, whether you have worked since the prior report and whether you have undertaken any additional schooling or vocational rehabilitation training. Your answers are valuable in updating the disability record about the severity and treatment of your impairment for subsequent adjudicators of the claim.

How to Fill out Form SSA-3441-BK?

  1. Complete all sections on the form with as much necessary information as possible to present a complete and full picture of you and your impairments. The information must be thorough and accurate. Even though some of it will be exactly the same as on your initial report, you still have to fill it out;
  2. Do not ask your health care provider to help you complete this form. However, you may ask other people, for example, your family member or a friend, to help you. It might be useful to work with an advocate or attorney, even before you begin the appeal process. If you have any questions, a representative from the local social security office can assist you, simply bring the form with you for your appointment;
  3. If you have any medical records, documents, or statements that might serve as a confirmation or evidence of what is written in the form and that the SSA does not already possess, you can bring or send them to their office along with the completed report. You can also bring your prescription medication if you have any;
  4. If you need more space to answer the questions, feel free to use the «Remarks» section on page 8 of the form, submitting compelling information;
  5. Leave no boxes blank, and if a question does not apply to you, simply indicate that by writing «not applicable», otherwise, the blanks might delay the appeal process;
  6. Write down all the information about the disabled person - their full name, social security number, phone number, and email address;
  7. Identify your contacts - information on someone (not your doctor) who knows about your medical condition, and can help you with your claim. This person is for the SSA to contact;
  8. State if there has been any change in your mental or physical conditions and if you have any new physical or mental conditions;
  9. If you have used other names on your medical or educational records, indicate them;
  10. State if you have received medical treatment since you last notified the SSA, or if you have a future medical appointment scheduled;
  11. Identify your medical providers - the name of the office or facility, the dates of treatment, the kinds of tests. Mention doctors' offices, clinics, hospitals, mental health centers;
  12. State if anyone else has medical information about your mental or physical conditions;
  13. Answer if you are currently taking any prescription or non-prescription medicines;
  14. Write down if there has been any change in your daily activities due to your medical conditions;
  15. Describe your work and education if it changed somehow or if you enrolled in any type of training or school;
  16. State if you have used any employment, vocational rehabilitation, or other support services;
  17. After the form is properly filled out, deliver it along with all the necessary attachments to your local social security office.

SSA-3441-BK Related Forms

  1. Form SSA-3820-BK, Disability Report - Child is the main form you need to complete when you start a disability application on behalf of the minor. It requires a full description of your relationship to the child, and extensive details relating to the medical condition that causes the child's disability.
  2. Form SSA-3368-BK, Disability Report - Adult is a document used to explain the health problems that make it impossible for you to work. It contains the description of your medical condition, symptoms, medical history, medical treatment, and explanations of how your health condition prevents you from working and why you could not perform a past job and cannot perform other kinds of jobs.
  3. Form SSA-16, Application for Disability Insurance Benefits is a form used for applying for a period of disability or insurance benefits.
  4. Form SSA-16-INST, Reporting Responsibilities For Disability Insurance Benefits is an instruction form that describes the changes to be reported and how to do that. You need to notify the SSA if your mailing address changes, if a beneficiary dies, if your medical condition improves, by making a report online, by mail, telephone, or in person.
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