Form Ssa-3441-Bk - Disability Report - Appeal printable pdf download

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

If you complete this report on paper:

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Print or write clearly.

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Include a ZIP or postal code with each address.

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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.

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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.

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ANSWER EVERY QUESTION, unless this report indicates otherwise. You can write "don't

know," or "none," or "does not apply" if you need to.

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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 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).

Form Ssa-3441-Bk - Disability Report - Appeal