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This version of the form is not currently in use and is provided for reference only. Download this version of
Form SSA-3441-BK
for the current year.
Form SSA-3441-BK Disability Report - Appeal
What Is Form SSA-3441?
Form SSA-3441-BK, Disability Report - Appeal , is a form used for all reconsideration and hearings appeal requests concerning disability issues. It is required if you are initially denied benefits and you want to appeal the decision. Its purpose is to collect information about the claimant's impairment, for example, if there is any change for better or worse in the impairment and if there is any additional or new impairment.
Alternate Names:
- Form SSA-3441;
- SSA Form 3441;
- SSA Disability Report Appeal;
- Social Security Appeal Form.
Completing the SSA Disability Report Appeal helps the U.S. Social Security Administration (SSA) process your claim. The latest version of the SSA-3441 was released by the SSA on April 1, 2018 , with all previous editions obsolete. An SSA-3441-BK fillable form can be downloaded below.
You must complete this form to keep your claim active if you receive a notice from the SSA that says you have been found ineligible for benefits. The SSA notice tells you the reason for the denial, describes the process for filing your request to get a reconsideration or to start an appeal process. It also informs you of the deadline for submitting this request. This deadline is essential to keep your claim open and active.
How to Fill Out Form SSA-3441-BK?
Form SSA-3441-BK is a critical part of moving forward with your Social Security Disability (SSD) claim. It allows the applicant to update the information provided in the initial claim that was denied for some reason. The Social Security Appeal Form was designed to allow the SSA to receive an update of what has transpired since the last time they have prepared a disability report.
The report's objective is to let the SSA determine what medical providers and new physicians have treated you, what treatment has been undertaken exactly, what medical tests were done, whether you have worked since the prior report and whether you have undertaken any additional schooling or vocational rehabilitation training. Your answers are valuable in updating the disability record about the severity and treatment of your impairment for subsequent adjudicators of the claim.
- Complete all sections on the form with as much necessary information as possible to present a complete and full picture of you and your impairments. The information must be thorough and accurate. Even though some of it will be exactly the same as on your initial report, you still have to fill it out.
- Do not ask your health care provider to help you complete this form. However, you may ask other people, for example, your family member or a friend, to help you. It might be useful to work with an advocate or attorney, even before you begin the appeal process. If you have any questions, a representative from the local social security office can assist you, simply bring the form with you for your appointment.
- If you have any medical records, documents, or statements that might serve as a confirmation or evidence of what is written in the form and that the SSA does not already possess, you can bring or send them to their office along with the completed report. You can also bring your prescription medication if you have any.
- If you need more space to answer the questions, feel free to use the "Remarks" section on page 8. Leave no boxes blank, and if a question does not apply to you, simply indicate that by writing "not applicable," otherwise, the blanks might delay the appeal process.
- Write down all the information about the disabled person - their full name, social security number, phone number, and email address.
- Identify your contacts - information on someone (not your doctor) who knows about your medical condition, and can help you with your claim. This person is for the SSA to contact.
- State if there has been any change in your mental or physical conditions and if you have any new physical or mental conditions. If you have used other names on your medical or educational records, indicate them.
- State if you have received medical treatment since you last notified the SSA, or if you have a future medical appointment scheduled.
- Identify your medical providers - the name of the office or facility, the dates of treatment, the kinds of tests. Mention doctor's offices, clinics, hospitals, mental health centers.
- State if anyone else has medical information about your mental or physical conditions. Answer if you are currently taking any prescription or non-prescription medicines. Write down if there has been any change in your daily activities due to your medical conditions.
- Describe your work and education if it changed somehow or if you enrolled in any type of training or school. State if you have used any employment, vocational rehabilitation, or other support services.
After the form is properly filled out, deliver it along with all the necessary attachments to your local social security office.
Not what you were looking for? Check out these related forms:
- Form SSA-3820-BK, Disability Report - Child, is the main form you need to complete when you start a disability application on behalf of the minor;
- Form SSA-3368-BK, Disability Report - Adult, is a document used to explain the health problems that make it impossible for you to work;
- Form SSA-16, Application for Disability Insurance Benefits, is a form used for applying for a period of disability or insurance benefits;
- Form SSA-16-INST, Reporting Responsibilities for Disability Insurance Benefits, is an instruction form that describes the changes to be reported and how to do that. You need to notify the SSA if your mailing address changes, if a beneficiary dies, if your medical condition improves, by making a report online, by mail, telephone, or in person.
Download Form SSA-3441-BK Disability Report - Appeal
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