SSA-3441-BK 2007 free printable template

Form Approved OMB No. 0960-0144 SOCIAL SECURITY ADMINISTRATION DISABILITY REPORT - APPEAL For SSA Use Only Do not write in this box. - Related SSN Individual is filing Number Holder Date of Last Disability Report Reconsideration Request for Review by Federal Reviewing Official Request for ALJ Hearing SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON A. NAME First Middle Initial Last C. DAYTIME TELEPHONE NUMBER If you do not have a number where we can reach you give us a daytime number where...

How to fill out SSA-3441-BK

How to fill out SSA-3441-BK

1. Start by downloading the SSA-3441-BK form from the Social Security Administration website.
2. Read the instructions carefully before beginning to fill out the form.
3. Provide your personal information at the top, including your name, Social Security number, and contact details.
4. Fill out the section about the disability and when it began.
5. List your medical treatment history, including doctors' names, addresses, and dates of treatment.
6. Document any medications you are taking and any other relevant factors concerning your disability.
7. Review your answers for accuracy and completeness before submitting.
8. Sign and date the form, then submit it to the appropriate Social Security office.

Who needs SSA-3441-BK?

1. Individuals applying for Social Security Disability Insurance (SSDI) benefits.
2. People who have previously applied for SSDI and need to provide additional information.
3. Individuals seeking to appeal a denial of benefits related to their medical condition.

• Who needs an SSA Form 3441-BK?
• What is an SSA Form 3441-BK for?
• Does an SSA Form 3441-BK require any accompaniment?
• • How do I fill out the Disability Report — Appeal form?
  • Where do I send the completed SSA Disability Report — Appeal form?

Who needs an SSA Form 3441-BK?

A person seeking Social Security Disability (SSD) Benefits whose initial claim has been denied can still appeal the decision. In order to make an appeal, an SSD benefits applicant must submit their Disability Report — Appeal (viz. SSA Form 3441-BK). The form was created by the Social Security Administration to enable the applicants to appeal the refusal in SSD benefits and provide additional details and documents that might aid in the reconsideration process.

What is an SSA Form 3441-BK for?

The Disability Report — Appeal form allows the applicant to update the disability information provided in the initial claim that was denied.

Does an SSA Form 3441-BK require any accompaniment?

The Disability Report — Appeal form should be supported by one of the following attachments depending upon the case:

• Request for Reconsideration (SSA-561-U2),
• Request for Reconsideration-Disability Cessation (SSA-789),
• Request for Hearing by Administrative Law Judge (HA-501).

If there are any statements or documents that can serve as an evidence or confirmation of what is claimed on the form (e.g. medical records), they should be attached.

How do I fill out the Disability Report — Appeal form?

The properly completed form must provide the following details:

1. Information about the disabled person (name, SSN, phone number and address)

2. Contacts of people who can be addressed for reference (name, address and phone number)

3. Medical conditions (how they changed since the initial claim)

4. Medical treatment (how it changed)

5. Information about the health care provider (filled out by the healthcare provider themselves)

6. Other information about the medical condition of the disabled individual

7. Activities

8. Work and education

9. Any remarks

Where do I send the completed SSA Disability Report — Appeal form?

The properly filled out form along with all the necessary attachments should be sent to the local Social Security Administration office.

 

Instructions and Help about SSA-3441-BK

People Also Ask about

How do I contact Social Security administrator?

We administer retirement, disability, survivor, and family benefits, and enroll individuals in Medicare. We also provide Social Security Numbers, which are unique identifiers needed to work, handle financial transactions, and determine eligibility for certain government services.

What does a Social Security administrator do?

Form SSA- 827 (.pdf) SSA and its affiliated State disability determination services use Form SSA-827, "Authorization to Disclose Information to the Social Security Administration (SSA)" to obtain medical and other information needed to determine whether or not a claimant is disabled.

How to talk to a real person at the Social Security Administration?

You can call our National 800 Number at 1-800-772-1213 between 8:00 a.m. – 7:00 p.m., Monday through Friday. Wait times to speak to a representative are typically shorter early in the day (between 8 a.m. and 10 a.m. local time) or later in the afternoon (between 4 p.m. and 7 p.m. local time).

What is Social Security Administration authorization?

If you would like to receive your Social Security Statement by mail, please print and complete a "Request For Social Security Statement" (Form SSA-7004) and mail it to the address provided on the form. You should receive your paper Social Security Statement in the mail in four to six weeks.

Can you please call Social Security Administration?

To escalate a case, send an email or eFax to the representative to renew the original request and add the SSA field office management team as a “cc” on the email or eFax.

How do you escalate Social Security issues?

Click the "Let's Talk" Button Below and Ask One of Our Live Advisors Your Free Social Security Question!

For pdfFiller’s FAQs

Can I edit SSA-3441-BK on an iOS device?

Yes, you can. With the pdfFiller mobile app, you can instantly edit, share, and sign SSA-3441-BK on your iOS device. Get it at the Apple Store and install it in seconds. The application is free, but you will have to create an account to purchase a subscription or activate a free trial.

Can I edit SSA-3441-BK on an Android device?

You can make any changes to PDF files, like SSA-3441-BK, with the help of the pdfFiller Android app. Edit, sign, and send documents right from your phone or tablet. You can use the app to make document management easier wherever you are.

How do I complete SSA-3441-BK on an Android device?

On an Android device, use the pdfFiller mobile app to finish your SSA-3441-BK. The program allows you to execute all necessary document management operations, such as adding, editing, and removing text, signing, annotating, and more. You only need a smartphone and an internet connection.

What is SSA-3441-BK?

SSA-3441-BK is a form used by the Social Security Administration (SSA) to collect information about changes in a person's disability status, particularly for those receiving Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI).

Who is required to file SSA-3441-BK?

Individuals who are receiving Social Security Disability benefits and need to report changes in their condition, medical treatment, or work activity are required to file SSA-3441-BK.

How to fill out SSA-3441-BK?

To fill out SSA-3441-BK, individuals must provide personal information such as their name, Social Security number, and details about their medical condition, treatment, and work activity. It is important to read the instructions carefully and provide accurate information.

What is the purpose of SSA-3441-BK?

The purpose of SSA-3441-BK is to assess the continuing eligibility of individuals for disability benefits by gathering updated information about their medical condition and ability to work.

What information must be reported on SSA-3441-BK?

Information that must be reported on SSA-3441-BK includes changes in medical treatment, new diagnoses, changes in work status, and any improvements or worsening of the individual's disability.