Form Ssa-3441-Bk - Disability Report - Appeal Page 8
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10SECTION 5 – OTHER MEDICAL INFORMATION
5. Since you last told us about your other medical information, does anyone else have medical information
about any of your physical or mental conditions (including emotional and learning problems) or are you
scheduled to see anyone else?
This may include:
•
workers’ compensation
•
vocational rehabilitation services
•
insurance companies who have paid you disability benefits
•
prisons and correctional facilities
•
attorneys
•
social service agencies
•
welfare agencies
•
school/education records
□
Yes (Please complete the information below.)
□
No (Go to SECTION 6 – MEDICINES)
Name of Organization
Claim or ID Number
(if any)
Address
City
State/Province ZIP/Postal Code
Country (if not U.S.)
Name of Contact Person
Phone Number
Date of First Contact
Date of Last Contact
Date of Next Contact (if any)
Reasons for Contacts
If you need to list more people or organizations, use SECTION 10 – REMARKS on the last page.
SECTION 6 – MEDICINES
6. Are you currently taking any medicines (prescription or non-prescription)?
□
Yes (Please complete the information below. You may need to look at your medicine containers.)
□
No (Go to SECTION 7 – ACTIVITIES)
IF PRESCRIBED,
SIDE EFFECTS
REASON FOR MEDICINE
NAME OF MEDICINE
NAME OF DOCTOR
YOU HAVE
If you need to list more medicines, use SECTION 10 – REMARKS on the last page.
Form SSA-3441-BK (03-2015) ef (03-2015)
Page 6
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