SSA-3373 (Formerly SSA-3373-BK) 2004 free printable template

FUNCTION REPORT ADULT — Form SSA-3373-BK READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM IF YOU NEED HELP If you need help with this form, complete as much of it as you can and

How to fill out function adult ssa form

How to fill out SSA 3373-BK

1. Obtain the SSA-3373-BK form from the Social Security Administration (SSA) website or your local SSA office.
2. Start by filling out your personal information, including your name, Social Security number, and contact information at the top of the form.
3. In Section 1, provide details about your medical conditions and how they affect your daily activities.
4. In Section 2, describe your work history and any jobs you have had in the past, including job titles, duties, and dates of employment.
5. In Section 3, detail your daily activities and how your medical condition limits you in performing these activities.
6. Provide additional information regarding your treatment, including any medications you are taking and the names of your healthcare providers.
7. Review your answers carefully to ensure all information is accurate and complete before submitting the form.
8. Sign and date the form before submitting it to the SSA.

Who needs SSA 3373-BK?

1. Individuals applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) due to physical or mental impairments.
2. People who need to provide detailed information about their daily functioning and limitations due to their health conditions.

• Who needs an SSA-3373-BK Form?
• What is an SSA-3373-BK Form Used for?
• Is an SSA-3373-BK Form Accompanied by Other Forms?
• • What Information Should be Provided in an SSA-3373-BK Form?
  • How do I fill out an SSA-3373-BK Form?
  • Where do I send an SSA-3373-BK Form?

Who needs an SSA-3373-BK Form?

People who want to report their illnesses, conditions or injuries limiting their lives should use this form.

What is an SSA-3373-BK Form Used for?

This form is an essential paper while applying for any kind of benefits from the employer or government. While asking for some aid you will automatically explain how your life is limited and how the requested benefit can help you.

Is an SSA-3373-BK Form Accompanied by Other Forms?

An SSA-3373-BK Form is not accompanied by other forms. It doesn't need any attachments as well. If you lack some space while answering some questions you can use a “REMARKS” section on the leis page of the form.

What Information Should be Provided in an SSA-3373-BK Form?

• Disabled person's name

• Social Security Number

• Phone number

• Habitation information

• How do reported circumstances limit your ability to work

• Information about daily activities

• Information about abilities

• Medicines taken

• Etc

How do I fill out an SSA-3373-BK Form?

You shouldn't leave fields blank. If you are not sure about the answer you should either call a Social Security and ask them for help or simply write “Don't know”. This form doesn't require any special knowledge. This is made for you to fill it out on your own. If either the explanation is asked for or you need to explain the answer, be sure to explain the answer. If you need some more space to answer any question, there's “REMARKS” section on the last page for it. Don't forget to write the number of question being answered while using the “REMARKS” section.
Don't write on the “For SSA Use Only” section.

Where do I send an SSA-3373-BK Form?

It is sent to the establishment which made a request for it.

People Also Ask about function report 3373 bk

What is the function report SSA 3373?

The Function Report is a 10-page form that asks about your daily activities and how your health conditions affect your ability to work or go through life. It's also one of the main forms you'll fill out when you apply for Social Security disability benefits. It's also one of the most important forms in the application.

What is Section B of the SSA 3373?

Section B — Information about your illnesses, injuries, or conditions. Section B is only one question. it requires you to give the SSA a brief description of the conditions and symptoms you are dealing with.

What is SSA-3373-BK?

What Is Form SSA-3373-BK? Social Security Form SSA-3373-BK is a lengthy form that you fill out as a part of the process of applying for Social Security Disability benefits. It also goes by the Adult Disability Report or the Adult Function Report.

Why did I receive a SSA-3373-BK?

DDS requires the completion of the SSA-3373 when they do not have enough information in the medical records to determine whether the person's impairments are keeping them from being able to function in a work environment.

What is form SSA-3373-BK function report?

Form SSA-3373-BK is used to report an adult individual's ability to function. The Adult Function Report is used by the Social Security Administration as part of the criteria used to determine whether an individual qualifies to receive disability payments. This form should be completed with as much detail as possible.

Why did I get SSA 3373 form?

Typically, the process of applying for disability begins with you filing an initial claim for benefits and submitting a Form SSA-827 to release your medical records. If those medical records don't provide enough information to make a decision, then the SSA will typically ask you to fill out Form SSA-3373-BK.

Who fills out SSA 3373?

After you have made a Social Security Disability claim and have had your initial interview, you may be asked to fill out Form 3373-BK, the Adult Disability Report. This form is designed to be filled out by yourself, without the aid of medical or other professionals.

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What is SSA 3373-BK?

SSA 3373-BK is a form used by the Social Security Administration (SSA) to collect information about an individual's work history and the impact of their medical conditions on their ability to work.

Who is required to file SSA 3373-BK?

Individuals applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) benefits are required to file SSA 3373-BK.

How to fill out SSA 3373-BK?

To fill out SSA 3373-BK, provide detailed information about your medical conditions, work history, daily activities, and how your conditions affect your ability to perform work-related tasks. Follow the instructions carefully and ensure all sections are completed.

What is the purpose of SSA 3373-BK?

The purpose of SSA 3373-BK is to gather relevant information to evaluate an individual's eligibility for disability benefits by assessing their medical conditions and the extent to which these conditions limit their functional abilities.

What information must be reported on SSA 3373-BK?

The SSA 3373-BK must report information on the applicant's medical conditions, treatment history, work history, daily activities, and specific limitations resulting from their medical issues.