Form SSA-3441-BK Disability Report-Appeal

APPEAL: The SSA-3441-BK (Disability Report-Appeal) is the form used to update disability information. It is used in conjunction with the SSA-561-U2 (Request for Reconsideration), SSA-789 (Request for Reconsideration-Disability Cessation), or HA-501 (Request for Hearing by Administrative Law Judge) when filing an appeal based on disability. Before determining whether you should complete this form, you need to refer to the SSA-561-U2, SSA-789, and HA-501 and determine whether one of those forms is the appropriate one to complete.

If you determine you need to complete an SSA-561-U2, SSA-789, or HA-501, and your disability claim was denied, or your disability benefits were stopped, because we determined you do not meet, or no longer meet, our disability requirements, you need to complete the SSA-3441-BK. If you are uncertain whether this is the appropriate form, review the letter you received. It will tell you why we denied your application or stopped your benefits.

EVIDENCE: When you file the appeal request, you should give us any evidence you have that shows why the determination we made was incorrect. This would include copies of any medical records you have that we did not consider in our previous determination.

You will also need to provide sufficient copies of the form SSA-827 (Authorization to Disclose Information to SSA). Count the number of sources you list in Section 3 on the SSA-3441-BK and add two extra copies.

The following section explains how to complete the SSA-3441-BK. If you have further questions about the form, or any other Social Security matter, you may call 1-800-772-1213 or contact your local Social Security office. If you are deaf or hard of hearing, call our toll-free “TTY” number, 1-800-325-0778. Representatives are available Monday through Friday from 7 a.m. to 7 p.m. Please have available any letters you received from us.

Below you will find the FORM SSA-3441-BK Disability Report-Appeal in Portable Document Format (PDF) .

The PDF permits you to print out a duplicate of the original form using ANY graphics printer. The PDF was developed by Adobe Systems, Inc. and allows the reader to print a publication close in appearance to the original printed version, preserving typography, columns, charts, tables and graphics. To read and print a PDF publication, you must have the Adobe Acrobat Reader software installed on your PC. Adobe Systems, Inc. permits the Social Security Administration and other organizations to offer this software to the public free of charge.

Below you will this form in Portable Document Format (PDF). To print the PDF version, you will need the Adobe Acrobat reader software. If you do not already have this special software, you can download and install it for free at the Adobe website.

PDF files are printer independent using any printer. If you are using the software to view SSA forms, the form should be printed on 8 1/2" x 11" white paper. You must print the form with blue or black ink to be acceptable to SSA.

If you need further information, Customer Support is available at Adobe's website.

Please do not contact the Social Security Administration for problems or questions concerning the Adobe Reader software.

After you download the Adobe Acrobat Reader, come back to this page and download the PDF version of the SSA-3441-BK below.

SSA-3441-BK in

DATE OF LAST DISABILITY REPORT:

Complete the information from the date you last completed a disability report form to the date you are now completing the SSA-3441-BK. If you don’t know the exact date, use the closest date you can remember. Checking the date on the determination notice you received in the mail may also help you remember. If you completed a disability report over the Internet, look for the date on any pages you may have printed and saved.

SECTION 1: Complete this section to give us your name, daytime telephone number, and name of a friend or relative that we can contact.

SECTION 2: This part asks you to record changes in your medical condition since you last completed a disability report form. Answer the questions and describe all “yes” answers accordingly.

SECTION 3: This part asks you to identify medical sources we may contact for further information about your condition. Be sure to include any doctors, HMOs, therapists, hospitals, clinics or any other sources of medical information. Only list those sources where there would be records since you last completed a disability report form. Be sure to list all the information regarding name, address, and phone of the source, even if they were listed on your last disability report form. Be as specific as possible with the dates, reasons, and treatments for the sources listed.

SECTION 4: Complete this section to show whether you are taking any medications.

SECTION 5: Complete this section to show whether you have had, or are scheduled to have, any medical tests since you last completed a disability report form.

SECTION 6: If you have worked since you last completed a disability report form, you need to report that work. Contact your local Social Security office or call us at one of the phone numbers shown above under “EVIDENCE” for information regarding how this may affect your appeal and the form(s) needed to report that work.

SECTION 7: Be as specific as possible in describing what assistance you may need in caring for yourself. If you have changed your activities since you last completed a disability report form, describe these changes and what prompted them.

SECTION 8: Complete this section to show whether you have had any special job training, trade or vocational school since you last completed a disability report form.

SECTION 9: Complete this section to show whether you have had any vocational rehabilitation, employment, or other support services since you last completed a disability report form.

SECTION 10 : You can use this section as a continuation for prior questions, making sure you show the question number to which you are referring. You can also use this section to show any other information you feel we should consider in the appeal process. You may use any blank sheet of paper as an additional continuation sheet- make sure you write at the top of the sheet your name, Social Security number, and “SSA-3441-BK-CONT.”

Also be sure to complete the blocks at the end of this section.

Social Security Appeals Process

Forms:

• SSA-561-U2 , Request for Reconsideration
• SSA-789 (Request for Reconsideration-Disability Cessation)
• HA-501 (Request for Hearing by Administrative Law Judge)
• SSA-827, Authorization to Disclose Information to SSA