i3441 (iAppeals) Disability Report--Appeal (i3441--Revisions to the Scree

iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

17

How the Online Appeal Disability
Report Works

OMB No. 0960-0144

You are now starting the online Appeal Disability Report, which is Part 2 of
the Internet Appeal process. The Appeal Disability Report (SSA-3441) on the
following pages will ask you to describe any changes that have occurred since
you last completed a disability report. This will include information about your
condition, medical sources and treatments, work activities and education. If you
need to find a ZIP code for an address, use the ZIP Code Lookup.
Completing and Saving the Appeal Disability Report:
The report does not have to be done all at once. After you complete the
next page, we will give you a Reentry Number. You will be able to stop
working on the report whenever you want and then use this Reentry
Number to come back to the section where you left off.
We estimate you will need 120 minutes to complete this Appeal Disability
Report. If you want more information, use this link to read about the
Paperwork Reduction Act.
In each section of the report you will be asked to enter information. We
will give you instructions and examples to guide you.
At the end of each section, you will have a chance to review your answers
and add or change information.
After you complete a page, some answers are protected and cannot be
changed by going back to that page. If you need to make changes to a
protected answer on a completed page, continue with the report. You will
be able to change your answer from the summary page at the end of the
section.
When you have completed the report, you will see a full summary of the
information you entered. You can make any necessary changes and then
print or save a copy of this summary for your records. If you want to keep
a copy of the entire report for your records, you will need to print or save
each page using your browser's print command.
If you do not have enough room to enter all the information you want to
give us on the report, including the Remarks block in the Review and
Send section, please write the information on a separate sheet of paper
and send it to us at the address we will give you after you've completed
this report.
How to Move Around in the Report
To move forward page by page in order in the report, select the Continue
button at the bottom of the page.
To move from section to section in the report, use the Tabs at the top of
the page. Using a Tab takes you to the first page of a section. If the Tabs
are not "dimmed," you can use them to go to any section at any time.
If you are navigating using only the keyboard or using an assistive device
and need help, visit our instructional page for alternative views and
navigation. Note: If you select this link, you will leave this secure site and
go to a new browser window. You will automatically return to this page
when you close the new browser window.
Once you have reached a Summary page in a section, you may return to
it by using the Return to Summary button at the bottom of a page in that
section.
Additional buttons, other than Continue and Previous Page, may appear
at the bottom of a page. These buttons allow you to take an action, such
as deleting a page or returning to the summary.
Additional information may appear in a new browser window. Close that
window to return to the appeal process.
IMPORTANT
Do NOT use the Enter key to move around in the
report or to select from the drop-down lists.
To move backward page by page in order in the
report, select the Previous Page button at the bottom
of the page. Do NOT use the "Back" button on your
browser to move backward.
You will receive a time-limit warning if you stay
more than 25 minutes on any one page. Then you
can extend your time on that page. After the third
warning on a page, you must move to another
page or your time will run out and all your work on
that page will be lost. (NOTE: If you have turned
JavaScript off in your browser, you will not receive
these warnings and, after 30 minutes on a page, you
must go to another page or your disability report
session will end, and your work on the last page will
be lost.)
Special Instructions for Blind Users
Continue

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iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

18

About You: General Information

NOTE: Appeal
request was
completed.
If you are completing the Appeal Disability Report for someone other than
yourself, please remember that when we ask things “About You,” we mean the
adult or child whose disability decision is being appealed (the “Claimant”).
The Claimant’s name, address and phone number were entered on the Appeal Request.

Claimant’s Name

John Public

(First, Middle, Last)

Address
(Street Line 1)
(Street Line 2)

Name and address
will be prefilled and
protected.
Phone number will
be prefilled but NOT
protected.

(City, State, Zip Code)

Telephone Number:

(XXX) XXX-XXXX

Example: (111) 222-3333

Extension:
We need to know how
to contact or leave a
message for the Claimant.
Select one:

This is the Claimant’s phone number.
The Claimant does not have a phone, but you can leave a message at this number.

Email Address:
(optional)

Continue

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iAppeals Screens for the final PSA (May 24)

19

iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

20

Print Your Reentry Number

Your Reentry Number is nnnnnnnn
Before going any further, we are giving you a Reentry Number. If you get
disconnected, or if you decide to work on the report again later, you will need this
number. It will allow you to come back to this report and continue where you left
off without losing any information you entered.

Please print this page (using the Print command in the browser)
or write down this Reentry Number nnnnnnnn
If you lose or forget your Reentry Number, you will have to begin this Appeal
Disability Report over again and you will lose all the information you already
entered.
Information about your Reentry Number
Remember to guard your Reentry Number carefully because it is the key
to reentering the Appeal Disability Report. Do not put it where an
unauthorized person can see it.
Social Security employees will never ask for a Reentry Number and they
cannot look up a Reentry Number for you. This is to protect your privacy.
To continue this Report later
1. Wait at least 5 minutes
2. Go to http://www.socialsecurity.gov/appeal
3. Select ‘Go Back to the Report I Already Started’
4. Enter the Claimant’s Social Security Number and the Reentry Number
shown above
Result: We will bring you back to this report.
If you have any questions, you may contact us
By phone at our toll-free number, 1-800-772-1213. If you are deaf or hard of
hearing, call our toll-free ‘TTY’ number, 1-800-325-0778. Representatives
are available Monday through Friday 7 AM to 7 PM.
In person at your local Social Security Office.
Continue

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iAppeals Screens for the final PSA (May 24)

21

Welcome Back!

After you enter the Claimant’s Social Security Number and the Reentry Number,
you will be taken to the place in the report where you left off.
If you want, you can review the information about How the Online Appeal
Disability Report Works.
If you had errors on a page that were not corrected when you signed off, you will
need to correct them now before you can continue to new pages.
Social Security
Number:
(without dashes or hyphens)

Reentry Number:

If you do not have your Reentry Number, you will not be able to continue with the
Appeal Disability Report you already began. You can start a new online Appeal
Disability Report up to 3 times. You can either begin the report again or contact
your local Social Security Office and they will help you. However, Social Security
cannot access your Reentry Number.
Previous Page

Last edited 4/6/2007 6:09 PM

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iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

22

Sign Off

If you want to, you can stop for now. You can submit a partial report, or
use another way to complete the report, or you can come back later to
where you left off and continue working on this report. You can also
review the parts you already completed and add or change information.
If you will not be able to return to this Internet Report
If you know now that you will not be able to return to this report, we urge
you to send us electronically whatever you have already finished. We will
contact you later for any missing information. However, to submit the
report electronically, you must have at least completed the About You
section and started the Medical History section. If this is true, and you
want to send us what you have finished:
1. Choose ‘Return to Appeal Disability Report’ below.
2. Go to the Review & Send tab at the top of that page.
3. Follow the instructions there to send us the Appeal Disability
Report.
To print or save this page, please use the Print button at the top of your
browser or the File menu commands.
There are other ways to complete the Appeal Disability Report:
Call our toll-free number, 1-800-772-1213. Explain that you don't
want to use the online appeal process but do want to appeal the
decision made in your case. If you are deaf or hard of hearing, call
our toll-free ‘TTY’ number, 1-800-325-0778. Representatives are
available Monday through Friday from 7 AM to 7 PM.
Contact your local Social Security Office and tell the representative
that you want to appeal the decision made on your case.
Print a paper SSA-3441 from the Internet. This form is in Portable
Document Format (PDF) and requires Adobe Reader to open and
print it. If you don't have Adobe Reader on your computer, use this
link to get a free copy of Adobe Reader.
If you live outside the United States, see Service Around the World.
If You Plan to Finish This Internet Report Later
1. Go to this web site: http://www.socialsecurity.gov/appeal
2. Select "Go Back to the Report I already started".
3. Type in your Social Security Number and the Reentry Number
shown below.
Result: You will be taken back to where you left off in the report.
DO NOT Forget Your Reentry Number!
Please print this page (using the Print command in the browser)
or write down this Disability Report Reentry Number nnnnnnnn
Do not give this number to anyone else. If you lose or forget your
Reentry Number, you will have to begin this Appeal Disability Report over
again and you will lose all the information you already entered. To ensure
your privacy, no one else can have access to your Reentry Number.
Social Security can help you start the process over again, but we cannot
access your Reentry Number. To have a record of your Reentry Number,
print this page and keep it in a safe place.
Return to Appeal Disability Report

Exit

Last edited 5/24/2007 3:21 PM

iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

29

Review and Send: Print Cover Sheet

You also need to print and sign a medical release form SSA-827 Authorization to
Release Information to SSA. The law requires us to have a signed authorization
form in order to get your medical records from your doctors or hospitals, and
from other sources that you gave us.
John Public's address is:

555 Main Street
Anywhere, MD 21087
John Public's daytime phone number is:

(540) 555-3579
Name and address of someone else Social Security can contact who knows about John
Public's condition and can help with his or her appeal:

June Public
555 Main Street
Baltimore, MD 21087
I have attached the following items:

Check all that apply:
___Medical Release Form
___Appointment of Representative Form
___Waiver of Right to Personal Appearance Form
___Medical Evidence
___Questionnaire for Children Form
___School Records
___Other (Please list below.)

1696 link is always
shown.
4608 link is shown
only if HA-501 and
user has selected
does not want to
appear at a
hearing.
Questionnaire &
school records
only if under 18
(see i3441 logic).

Name of person completing this disability report:

Date:

Mail or bring to:

SOCIAL SECURITY ADMINISTRATION
[address]
[telephone]

Name region is
dynamic text.
Prefilled from RS002
if exists, nothing
displayed if it does
not exist (in other
words, the name is
not requested)
Date is send date
prefilled from RS002

If You Have Printing Problems:

Please try again. If you are still unable to print this page, please continue.
Contact Social Security at the address and phone number we have provided to
tell us that you could not print the Cover Sheet.
Previous Page

Last edited 5/24/2007 3:33 PM

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iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

30

Review and Send: Print Your Medical
Release Form
You also need to print and sign a medical release form SSA-827 Authorization to
Release Information to SSA. The law requires us to have a signed authorization
form in order to get your medical records from your doctors or hospitals, and
from other sources that you gave us.
What you need to do:
1.
Use the link below to access the medical release form. The medical
release form is in Portable Document Format (PDF) and requires Adobe Acrobat
Reader to open it and print it. If you don't have Adobe Acrobat Reader on your
computer you can download a free copy. Use this link to get a free copy of the
Adobe Reader.
2.
Print the medical release form. You must print BOTH sides, front and
back.
3.
Sign and date the medical release form.
Note: All adults are required to sign the medical release form for themselves,
even if someone else is helping them with the appeal process. The only
exceptions are when the disabled person has a legal guardian or is deceased.
4.
Mail or bring the signed and dated medical release form along with the
cover sheet of this Appeal Disability Report and any other appeal forms you have
printed to Social Security at the address we will give you. DO NOT take any
forms to your doctor.
5.
If you already have copies of medical records from your doctor, you can
send or bring them to us. However, we do not recommend that you delay your
case by requesting medical records yourself. We can do this for you.
Here are instructions for completing the medical release form.
Please print one copy.
Authorization to Disclose Information to SSA
If You Have Printing Problems:
Please try again. If you are still unable to print the form, please continue. Contact
Social Security at the address and phone number we will give you later to tell us
that you could not print the medical release form.
Previous Page

Last edited 5/24/2007 1:52 PM

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iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

31

Review and Send: Confirmation

Thank you.
We received your Appeal Disability Report on [date] at [time]. We will process it
at your local Social Security Office (see address below).
We recommend that you read this entire page and then print or save it for your
records.
Important—Next Steps:
Please mail or bring the following items to your local Social Security Office at the
address below.
Signed and dated SSA-827, Authorization to Disclose Information to
SSA, and copies of any medical information you may already have on
hand.
Completed and dated cover sheet for this Appeal Disability Report with
any other items identified on the cover sheet that you need to submit.
If you were unable to print the SSA-827 (Authorization to Disclose Information to
SSA), please contact Social Security.
Your Local Social Security Office:
SOCIAL SECURITY ADMINISTRATION
[address]
[telephone number]
You can mail or bring these documents to a different Social Security Office. You
can use the Office Locator to find another Social Security Office.
What to Expect:
While we are processing your appeal, we may contact you for more
information or to set up an interview. We may ask you to fill out additional
forms.
If we need more medical evidence, we may ask you to see a doctor for a
special examination. We will pay for this.
If you have copies of medical records that you have not given to us
before, mail or bring them to your local Social Security Office.
Please contact Social Security, immediately, if you:
Go to a new doctor
Have a new medical test done
Have a change in your condition
Go to work
Change your address or phone number
For more information on the disability process, go to How the Disability
Appeal Process Works
Previous Page

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iAppeals Screens for the final PSA (May 24)

If You Do Not Want To Use This Online
Appeal Process

Other Ways to Request an Appeal or Complete a Disability Report
If you prefer not to complete a Request for Reconsideration or a Disability
Report on the Internet, you can use any of the following ways:
Call our toll-free number, 1-800-772-1213. Explain that you don't
want to use the online appeal process but do want to appeal the
decision made in your case. Representatives are available Monday
through Friday from 7 AM to 7 PM. If you are deaf or hard of
hearing, call our toll-free 'TTY' number, 1-800-325-0778.
Contact your local Social Security Office and tell our representative
that you want to appeal the decision made on your case.
Refer to your denial notice to find out the kind of appeal you need to
request. You can print the form you need from our Forms Page. In
addition to the Request for Reconsideration form, you will need to
print and complete a paper Appeal Disability Report (SSA-3441)
and an Authorization to Disclose Information to SSA (SSA-827).
After you print out and complete all three forms, you should mail or
take them to your local Social Security Office. We will be able to
take action more quickly if we receive all three forms at the same
time.
NOTE: You must have Adobe Reader on your computer to read and print
the forms. If you do not have a current version of Adobe Reader, use this
link to get a free copy of Adobe Reader.
If you live outside the United States, see Service Around the World.

Close this window to return to the appeal process.
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iAppeals Screens for the final PSA (May 24)

Privacy Information

The Social Security Act (sections 205(a), 702, 1631(e)(1)(a) and (b), and
1869(b)(1) and (c), and Public Law 106-169 (Section 809(a)(1) of Sections
251(a)) and Section 1839(i) of the Act (P.L. 108-173) as appropriate)
authorizes the collection of information on this form. We need the
information to continue processing your claim. You do not have to give it,
but if you do not you may not receive benefits under the Social Security
Act. We may give out the information on this form without your written
consent if we need to get more information to decide if you are eligible for
benefits or if a Federal law requires us to do so. Specifically, we may
provide information to another Federal, State, or local government agency
which is deciding your eligibility for a government benefit or program; to
the President or Congressman inquiring on your behalf; to an independent
party who needs statistical information for a research paper or audit report
on a Social Security program; or to the Department of Justice to represent
the Federal Government in a court suit related to a program administered
by the Social Security Administration. We explain, in the Federal Register,
these and other reasons why we may use or give out information about
you. If you would like more information, get in touch with any Social
Security office, the Veterans Affairs Regional Office in Manila, or any U.S.
Foreign Service post.
We may also use the information you give us when we match records by
computer. Matching programs compare our records with those of other
Federal, State, or local government agencies. Many agencies may use
matching programs to find or prove that a person qualifies for benefits paid
by the Federal government. The law allows us to do this even if you do
not agree to it.
Explanations about these and other reasons why information about you
may be used or given out are available in Social Security offices. If you
want to learn more about this, contact any Social Security office, the
Veterans Affairs Regional Office in Manila, or any U.S. Foreign Service
post.

Close this window to return to the appeal process.
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iAppeals Screens for the final PSA (May 24)

Paperwork Reduction Act

This information collection meets the requirements of 44 U.S.C. § 3507, as
amended by section 2 of the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a valid Office of
Management and Budget control number. The OMB Control Number for the
Internet Appeal Disability Report is 0960-0144. The expiration date for this
OMB Control Number is 8/31/2009. We estimate that it will take you an
average of 120 minutes to respond, but total time required will depend upon
the number of questions you need to answer for the Internet Appeal
Disability Report.
You may send comments on our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating
to our time estimate to this address, not the completed form.

If You Have Questions
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of
hearing, call our toll-free 'TTY' number, 1-800-325-0778. Representatives
are available Monday through Friday from 7 AM to 7 PM.

Close this window to return to the appeal process.
Last edited 4/13/2007 4:46 PM

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iAppeals Screens for the final PSA (May 24)

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iAppeals Screens for the final PSA (May 24)

Your Right To Representation

You can handle your own Social Security appeal with free help from Social
Security, or you can choose a lawyer, a friend or someone else to help
you. Someone you appoint to help you is called your “representative”.
You cannot choose someone who has been suspended or disqualified
from representing others before the Social Security Administration or who
may not, by law, act as a representative. You may contact your local
Social Security office for a list of legal referral and service organizations.
We will work with your representative, just as we would work with you.
If you want to appoint someone as your representative, you or your
representative must first complete Form SSA-1696 (Appointment of
Representative) or send a written statement naming your representative.
If your representative is not an attorney, he or she must sign the statement
or SSA-1696 or state in writing that he or she accepts the appointment,
before you send it to us.
Your representative cannot charge or collect a fee from you without first
getting written approval from Social Security. However, your
representative may accept money from you in advance as long as it is held
in a trust or escrow account.
Both you and your representative are responsible for providing us with
accurate information. It is illegal to furnish false information knowingly and
willfully. If you do, you may face criminal prosecution.
You can get more information about having a representative by selecting
the link Your Right to Representation.

If You Have Questions
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of
hearing, call our toll-free 'TTY' number, 1-800-325-0778. Representatives
are available Monday through Friday from 7 AM to 7 PM.

Close this window to return to the appeal process.
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iAppeals Screens for the final PSA (May 24)

Who Is The Wage Earner?

The Wage Earner is a person who earns Social Security credits while
working for wages or self-employment income. He or she is sometimes
referred to as the "Number Holder" or "Worker."
If the Claim Number is not your own Social Security Number, then the
Wage Earner is the spouse or parent on whose record you filed for
disability. You should enter his or her name in the space provided.
You may continue without providing this information.

If You Have Questions
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of
hearing, call our toll-free 'TTY' number, 1-800-325-0778. Representatives
are available Monday through Friday from 7 AM to 7 PM.

Close this window to return to the appeal process.
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iAppeals Screens for the final PSA (May 24)

40

About Your Notice and Claim Numbers

Your notice has information that can help you complete the appeal
request.
This example is just to show you where to look. In order to continue, your
notice title should be one of the following:
Notice of Disapproved Claim
Notice of Reconsideration
Notice of Federal Reviewing Official Decision

This is
your
Notice
title.

SOCIAL SECURITY ADMINISTRATION
Retirement, Survivors, and Disability Insurance
Supplement Security Income
Notice of Reconsideration
Date: [Month, Day, Year}
Claim Number: 000-00-0000 A
[Your Name]
[Your Address]

This is your
claim number,
including any
letter(s) at the
end.

You asked us to take another look at your claim for
Social Security disability benefits. Someone who did not
make the first decision reviewed your case, including any
new facts we received, and found that the first decision
was correct.

If You Have Questions
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of
hearing, call our toll-free 'TTY' number, 1-800-325-0778. Representatives
are available Monday through Friday from 7 AM to 7 PM.

Close this window to return to the appeal process.
Last edited 4/6/2007 6:12 PM

iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

41

You Cannot Use the Internet to
Complete Your Appeal Request

You do not meet one or more of the qualifications to file your request for
appeal using the Internet. To request an appeal, you should contact
Social Security immediately as explained below and tell them that you
received this message.
To contact Social Security:
Call our toll-free number, 1-800-772-1213. Explain that you are unable
to use the online appeal process but do want to appeal the decision
made in your case. If you are deaf or hard of hearing, call our toll-free
"TTY" number, 1-800-325-0778. Representatives are available
Monday through Friday from 7 AM to 7 PM.
Visit your local Social Security Office and tell the representative that
you want to appeal the decision made on your case.
Select the Exit button to leave this report. You will be taken to the Social
Security home page.
Exit

Last edited 5/16/2007 9:32 AM