How to Complete the Disability Report Appeal (SSA-3441-BK)

If the Social Security Administration denies your initial application for disability benefits, you can submit a request for reconsideration. This step in the appeals process requires submitting a Disability Report — Appeal (SSA-3441-BK) form. Read on to learn how to fill out this form correctly.

What is Form SSA-3441-BK?

Form SSA-3441-BK is a document you’ll need to file during the appeals process for disability benefits. The form is also known as the Disability Report — Appeal. This key piece of paperwork gives you a valuable opportunity to share any additional medical evidence, treatment history, or work history you’ve gained since the last time the SSA denied your case. Hopefully, presenting this fresh evidence will help you win the benefits you need.

How does disability reconsideration work? 

Most people are denied the first time they apply for SSDI or SSI. In 2022, only 35% of initial applications were approved. So chances are, you’ll have to go through at least part of the disability appeals process. There are four total stages of disability appeals:

1. Reconsideration

2. Hearing

3. Appeals Council review

4. Federal Court review

How to file for reconsideration

It is your right to appeal the SSA’s decision about your disability claim. To request a reconsideration, there are three official forms the SSA requires you to submit:

1. Form SSA-561-U2: This form serves as your official request to initiate a reconsideration and reopen your case. On it, you’ll include the reason why you disagree with the SSA’s decision to deny you disability benefits.

2. Form SSA-3441-BK, Disability Report — Appeal: This is the form we’re covering in this article. It gives you a place to update the SSA on changes in your medical condition and treatment.

3. Form SSA-827, Authorization to Disclose Information to the Social Security Administration: SSA-827 gives your doctors, family, or past employers permission to share information with the SSA about your disability and how it affects you. 

If you have any new medical records you haven’t yet given the SSA, you can also send them with Form SSA-3441-BK.

“The key point that many people overlook is that they must complete and submit the SSA-561, SSA-3441, and SSA-827 forms for their appeal to be considered complete. Submitting online ensures everything is covered, but for paper applications, separate forms need to be submitted." - Maegan Seawright, legal representative at Atticus

Sections of Form SSA-3441-BK

The part of the ten-page form you’ll need to begin filling out starts on page three. Here’s what to expect and the information to have handy for each section.  

Section 1 — Information About the Disabled Person

Add your full name, Social Security number, phone number, secondary phone number, and email address (this is optional).

Section 2 — Contacts

In this section, provide the name of somebody the SSA can contact who knows about your medical conditions and who can help you with your claim. This can be a friend or relative, but cannot be your doctor.

Write the person's name, relationship to you, full mailing address, phone number, and whether they can speak and understand English.

Indicate who is completing the form. If you (the disability applicant) or the person you mentioned in this section is filling it out, skip to Section 3. If someone else is completing the form, please provide their name, relationship to you, mailing address, and phone number in the remaining fields.

Section 3 — Medical Conditions

Since your initial disability application, describe in detail whether there has been any change (for better or worse) in your medical conditions, including the approximate date the change occurred if so. Since your initial disability application, describe in detail whether you have any new physical or mental conditions. If you have any, include when they started.

Section 4 — Medical Treatment

If you have used any other names on your medical or educational records (like a maiden name, other married name, or nickname), write those names on the form. Since your initial disability application, mark whether you have seen a healthcare provider, received any medical treatment, or have a future appointment scheduled. Use pages five, six, and seven to provide more detail on any new medical treatment you received from up to three providers in doctor’s offices, hospitals, emergency rooms, clinics, mental health centers, or any other healthcare facilities.

If needed, you can add details from additional new providers in the Remarks section. For each of these providers, you’ll need to provide their name, the address of their facility, your dates of treatment, and any past or upcoming tests.

Section 5 — Other Medical Information

Since you first applied for disability, think about anyone else who might have medical information about your physical or mental conditions, like welfare agencies, workers’ compensation, or vocational rehabilitation services. 

Add the name of the organization, your claim or ID number, the organization’s full address, the name and phone number of the contact person, and the dates of your first, last, and next appointments, along with the reasons for these contacts. If there is no one, you can skip to section six.

Section 6 — Medicines

For any medications you are currently taking (both prescription and non-prescription), fill out the medication name, the doctor who prescribed it (if applicable), the reason you take the medicine, and any side effects you experience.

Section 7 — Activities

Since your initial disability application, explain whether there has been any change (either good or bad) in your daily activities because of your physical or mental conditions. For example, think about your household tasks, personal care, social activities, hobbies and interests, and ease of getting around.

Section 8 — Work and Education

Note if your work activity has changed since you last reported about your work to the SSA. In this section, you’ll also disclose if you have started or completed any classes, such as GED classes, job training, trade school, vocational school, or college classes. If so, note the dates you attended and any degrees or certificates you earned.

Section 9 — Vocational Rehabilitation, Employment, or Other Support Services

If you have participated in vocational rehabilitation or support services to help you work, list the programs in this section. Include the instructor, their phone number, the organization’s full address, and the date you began the program.

Section 10 — Remarks

Use this section if you need extra space to answer any of the previous questions. Be sure to include the number of the question you’re answering. 

5 tips for completing Form SSA-3441-BK

Make sure your form is properly completed and submitted by following these tips:

1. Answer every question. If you need to, write “I don’t know,” “none,” or “does not apply” in the space provided. 

2. Fill out the form yourself. Your doctor or healthcare provider is not allowed to complete the report for you. However, you can get help from a friend, family member, or SSA representative. The best person to assist you with the form is a disability lawyer. They’re experienced with the reconsideration process and can advise you on how to fill out each section.

3. File the paperwork on time. If you’re submitting a disability appeal, you must submit your request for reconsideration (including Form SSA-3441-BK, Form SSA-561-U2, and Form SSA-827) within 60 days of the date you received your denial.

4. Print or write clearly. Your handwriting needs to be easily legible so the SSA can read everything they need to know. (Instead of filling out the application by hand, you can also fill it out online.)

5. Include new medical evidence. If you have had any new medical testing or treatment or received new diagnoses within the last 90 days (the kind of information you described in section four of the form), enclose these records with your appeal. They will help strengthen your claim by providing more “proof” to the SSA that you need benefits.

How to submit Form SSA-3441-BK

When you’ve completed the disability report appeal form, and you’re ready to submit it (along with Form SSA-827 and Form SSA-561-U2), you can do so in any of the following ways:

• Online via your ssa.gov account

• Through the mail

• By visiting your local SSA office in person (locate your nearest office by ZIP code)

Get help for your disability appeal

The disability appeal process is not easy or straightforward — and to further complicate matters, it’s crucial to file all of the right paperwork on time. A lawyer can help walk you through the SSA 3441 Disability Report - Appeal form, plus the other documents you need. Get started by taking our two-minute disability quiz to let us know more about your situation. Someone from our team can provide free advice about your options. If you’d like, we can introduce you to a lawyer to help you navigate your claim at no upfront cost.