DisabilityReport-AppealSSA-3441-BKDISABILITY REPORT - APPEAL - Form SSA-3441-BK
READ ALL OF THIS INFORMATION BEFORE YOU BEGIN
COMPLETING THIS FORM
HOW TO COMPLETE THIS FORM
ABOUT YOUR MEDICAL RECORDS
We will use the information that you give us on this form to update your disability report
information for your appeal. We will use the form to update your disability information since
you last completed a disability report. Please complete as much of the form as you can. If
you need help, your interviewer will help you finish it. If you have an appointment for an
interview by telephone, have the form ready to discuss with us when we call you. If you have
an appointment for an interview in our office, bring the completed form with you or mail it
ahead of time, if you were told to do so. If you have access to the Internet, you may access the
Disability Report Form - Appeal instructions at http://www.ssa.gov/online/ssa-3441.html.
If you are filling out the form for someone else, please provide information about him or her.
When a question refers to "you," "your," or the "Disabled Person," it refers to the person who
is applying for or has been entitled to disability benefits.
• Print or write clearly.
• DO NOT LEAVE ANSWERS BLANK. If you do not know the answers, or the answer
is "none" or "does not apply," please write: "don't know," or "none," or "does not apply."
• IN SECTION 3, PUT INFORMATION ON ONLY ONE
DOCTOR/HMO/THERAPIST/OTHER/HOSPITAL/CLINIC IN EACH SPACE.
• Each address should include a ZIP code. Each telephone number should include an area code.
• DO NOT ASK A DOCTOR OR HOSPITAL TO COMPLETE THIS FORM.
However, you can get help from other people, like a friend or family member.
• Be sure to explain an answer if the question asks for an explanation, or if you want to give
If you need more space to answer any questions or want to tell us more about an answer,
please use Section 10 - REMARKS on Page 7, and show the number of the question being
If you have any medical records o