Form Ssa-3441-Bk - Disability Report - Appeal Page 6
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10SECTION 4 – MEDICAL TREATMENT (continued)
Provider 2
4. D. Name of facility or office
Name of health care provider who treated you
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone Number
Patient ID# (if known)
Address
City
State/Province
ZIP/Postal Code
Country (if not U.S.)
Dates of Treatment (approximate date, if exact date is unknown)
Office, Clinic or Outpatient visits at
Emergency Room visits at
Overnight hospital stays at
this facility
this facility
this facility
First Visit _________________
Date __________________
Date in _____ Date out _____
Last Visit _________________
Date __________________
Date in _____ Date out _____
Next scheduled appointment
Date __________________
Date in _____ Date out _____
(if any) ___________________
o None
o None
What medical conditions were treated or evaluated?
What treatment did you receive for the above conditions? (Do not list medicines or tests in this box.)
Has this provider performed or sent you to any tests? Please include tests you are scheduled to have in the
□
□
future.
Yes (Please complete the information below.)
No (Go to the next page.)
DATES OF
DATES OF
KIND OF TEST
KIND OF TEST
TESTS
TESTS
□
□
Biopsy (list body part)
MRI/CT Scan (list body part)
__________________
___________________
□
□
Blood Test (not HIV)
Speech/Language Test
□
□
Breathing Test
Treadmill (exercise test)
□
□
Cardiac Catheterization
Vision Test
□
□
EEG (brain wave test)
X-ray (list body part)
□
__________________
EKG (heart test)
□
□
Hearing Test
Other (please describe)
□
HIV Test
__________________
□
IQ Testing
If you need to list more tests, use SECTION 10 - REMARKS on the last page.
If you do not have any more providers to describe,
go to SECTION 5 – OTHER MEDICAL INFORMATION on page 6.
Form SSA-3441-BK (03-2015) ef (03-2015)
Page 4
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