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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.
How To Complete The SSA-3441-BK Disability Report-Appeal
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:
HOW TO OBTAIN THE SSA-3441-BK 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. You can download the Adobe Acrobat Reader
version suitable for your system by clicking on this button  .
After you download the Adobe Acrobat Reader, come back to this page
and download the PDF version of the SSA-3441-BK below. PDF files are printer
independent and should print easily on any graphics printer (i.e., laser,
inkjet, dot-matrix).
HOW TO SUBMIT THE SSA-3441-BK TO SSA Print the PDF
SSA-3441-BK form on 8 1/2 x 11 inch white paper, complete the form,
fold
in thirds, insert it in a standard size number 10 business envelope (4
1/8 x 9 1/2) and mail to your closest Social Security office. If you
are
not sure where your local office is located, try our Social
Security Office Locator service or call
1-800-772-1213.
SSA-3441-BK in 
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www.socialsecurity.gov
