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. Form SSA-795. Since you last told us about your vocational rehabilitation, h. ave you participated, or are you participating in: Access your account to see all saved docs. Official website of the U.S. Social Security Administration. Download a copy of the form SSA-3441-BK here. TN 5 (06-20) DI 12095.030 SSA-3441-BK (Disability Report - Appeal) A. We, may also disclose information to another person or to another agency in accordance with approved. This page is for requesting a hearing. Since you last told us about your medical conditions. 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. (e.g., to the Government Accountability Office and Department of Veterans Affairs); 3. Send or bring this completed report to your local Social Security office. If you receive a Benefit Verification letter, sometimes called a “budget letter,” a “benefits letter,” a “proof of income letter,” or a … 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. This website is produced and published at U.S. taxpayer expense. type(s) of condition(s) were you treated for, or will you be seen for? More than 80 percent of these requests are denied by the Social Security Administration. 8. and can help you with your claim. Related SSN - - Number Holder Date of Last Disability Report Individual is filing: Reconsideration Request for Review by Federal Reviewing Official Reconsideration for Disability … Someone else (Please complete the information below). go to SECTION 5 – OTHER MEDICAL INFORMATION on page 6. You must submit the form before the SSA’s deadline, or you risk having to start over from the beginning with your application. You do not need to answer these questions unless we display a valid, Office of Management and Budget control number. On average this form takes 66 minutes to complete. Please print, type, or write clearly and answer all items to the … Name of Person Making Statement (If … 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. Page 1. R continuing disability determination or evaluating any request for a hearing. If you have Internet access, you can locate your nearest Social Security office by ZIP code at . Form SSA-3441-BK (08-2010) ef (08-2010) Destroy Prior Editions SOCIAL SECURITY ADMINISTRATION DISABILITY REPORT - APPEAL Form Approved OMB No. the instructions, gather the facts, and answer the questions. Furnishing us this information is voluntary. If You Disagree With A Non-Medical Decision. Form SSA-3441-BK, Disability Report - Appeal is a form used for all reconsideration and hearings appeal requests concerning disability issues. If yes, please list the other names used: 4. Include a ZIP or postal code with each address. The form specifically asks about any changes in your medical condition, new limitations, and new treatment since you filed the last a disability report. Form SSA-3441 | Disability Report - Appeal. We will use the information. The person listed in 2.A. page, SECTION 10. We rarely use the information you provide on this form for any purpose other than to update your disability, information. The Social Security Administration (SSA) has a strict deadline for appeals. 5. Name of Wage Earner, Self-employed Person, or SSI Claimant. DISABILITY REPORT - APPEAL - Form SSA-3441-BK READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM We will use the information that you give us on this form to update your disability report information for your appeal. However, we may use it for the administration and integrity of Social Security programs. Form SSA-3441-BK (03-2015) ef (03-2015) Destroy Prior Editions SOCIAL SECURITY ADMINISTRATION. Get Form. It may seem repetitive, but the more effort you invest, the stronger your form and appeal will likely be. 3. an individual work plan with an employment network under the Ticket to Work Program? If you need more space to answer any question, please use the REMARKS section on the last. Since you last told us about your medical treatment, provider, received treatment at a hospital or clinic, or. 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. Edit & Download Download . Many forms must be completed only by a Social Security Representative. Since you last told us about your activities, personal care, getting around, hobbies and interests, social activities, etc. Since you last told us about your education, If yes, what type? The Form SSA-3441-BK DISABILITY REPORT - APPEAL form is 16 pages long and contains: 0 signatures. Having trouble downloading PDF files or with the PDF editor. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. Show details. Only list the providers you have seen since you last told us about your medical treatment. The REMARKS SECTION on the last page Dates: 06/26/2020 - Present Previous | Next Social! 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