WebThe person who is applying for disability. (Go to Section 3 - Medical Conditions) 2.G. Name (First, Middle Initial, Last) 2.I. Daytime Phone Number 2.H. Relationship to Person Applying 3.A. List all of the physical or mental conditions (including emotional or learning problems) that limit your ability to work. WebJan 18, 2024 · SSA-3441-BK, Disability Report - Appeal, and; SSA-827, Authorization to Disclose Information to the Social Security Administration. Form HA-501-U5. This …
Disability Report -- Appeal -- Form SSA-3441-BK
WebSECTION 2 - INFORMATION ABOUT YOUR ILLNESSES, INJURIES, OR CONDITIONS PAGE 1 Form SSA-3441-BK (08-2010) ef (08-2010) Destroy Prior Editions Approximate date the changes occurred: Month Day Year B. Approximate date the changes occurred: Month Day Year Yes No If "Yes," please describe in detail: If "Yes," please describe in … WebAppeal Medical Decision If you do not wish to appeal a medical decision online, you can use the Form SSA-561, Request for Reconsideration. You will also need to submit: Form SSA-3441, Disability Report - Appeal, and Form SSA-827, Authorization to Disclose Information to the Social Security Administration. If You Disagree With A Non-Medical … riverpoint apartments dallas tx
DISABILITY REPORT- APPEAL - Mathis Disability Advocates
WebDec 9, 2024 · Form SSA-3441-BK Disability Report--Appeal ( ) ⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0960-0144 can be found … WebAug 14, 2024 · Generally, a claimant also completes and submits the SSA-3441-BK “Disability Report—Appeal” (OMB No. 0960-0144) along with the appeal request. The SSA-3441-BK collects updated information relevant to a claimant’s appeal, including: The contact information of a friend or relative with knowledge of the claimant’s medical … WebForm SSA-3441-BK (08-2010) ef (08-2010) Destroy Prior Editions SOCIAL SECURITY ADMINISTRATION DISABILITY REPORT - APPEAL Form Approved OMB No. 0960 … smock cards