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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Form SSA-3441-BK Disability Report - Appeal
Form SSA-3441-BK Disability Report - Appeal
Form SSA-3441-BK Disability Report - Appeal
Form SSA-3441-BK Disability Report - Appeal
Form SSA-3441-BK Disability Report - Appeal
Form SSA-3441-BK Disability Report - Appeal

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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