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SSA Form SSA-3441-BK, known as “Disability Report – Appeal,” is required when an individual’s initial claim for disability benefits has been denied and they seek to appeal the decision. It collects updated information about the claimant’s medical condition, any new treatments, changes in daily activities, and work status since the last report was submitted. The form plays a critical role in providing the SSA with comprehensive and current details that might support the claimant’s case in the appeal.
The form is integral to the appeals process as it allows claimants to present new or additional evidence that could affect the outcome of their appeal. By filling out SSA Form SSA-3441-BK, individuals can document changes in their medical condition, including any worsening of their disability, new diagnoses, or changes in their ability to work and perform daily functions. This updated information is crucial for SSA reviewers to assess the continued eligibility or adjustment of benefits in light of the most recent health developments.
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What it is: The office that makes the disability decision on your case will use the information you provide in the Disability Report (Appeal), Form SSA-3441-BK, to update your disability appeal.
Where and when to file: Send or bring the completed report to your local Social Security office.
You do not need to ask doctors or hospitals for any medical records.
Names, addresses, and phone numbers of two people (other than your doctors) who know about your medical condition(s).
Information about any education, and any vocational rehabilitation, employment, or other support services, since you last told Social Security.
Names, addresses, and phone numbers of any healthcare providers, and any prescription or non-prescription medicines you take.
Name(s) of organization(s) that would have medical information about your condition(s) since you last told Social Security.
A question that refers to you or your refers to the person who is applying for disability benefits. If you are completing this report for someone else, provide information about them.
Enter your name in 1.A and your Social Security number in 1.B.
1.C: Have you used any other names on your medical or educational records, such as maiden name or nickname? Mark YES and list names used, or mark NO.
Enter your mailing address (street or PO Box) in 1.D, including apartment number, if applicable, then your city, state/province, ZIP/postal code and, if not USA, your country.
Enter your email address in 1.E.
In 1.F, enter Primary and, if available, Secondary daytime phone numbers where you can be called to speak or leave a message, if needed, with area code or IDD and country code if outside the USA or Canada.
1.G: Can you speak and understand English? Mark YES or NO; if NO, enter what language is preferred. If you cannot speak and understand English, an interpreter will be provided free of charge.
Mark YES or NO in 1.H (read and understand English) and 1.I (write more than your name in English).
Mark YES or NO: is there someone to contact who can help with your claim, if needed? Examples include a family member, friend, or neighbor.
If YES, provide the names of two people (other than your doctors) to contact who know about your medical condition(s) and can help you with your claim and can help reach you if you become unavailable.
If NO, providing at least one contact, if available, is recommended. Providing the name of someone who knows you may help make a decision on your claim.
For the first person, enter the name in 2.A, the relationship to the person in 1.A in 2.B, and the mailing address in 2.C with apartment number, if applicable.
In 2.D, enter the daytime phone number as described in 1.F. In 2.E, mark YES or NO: can this person speak and understand English? If NO, enter what language is preferred.
Enter the second person in 2.F to 2.J in the same way as the first person in 2.A to 2.E, marking YES or NO in 2.J and, if NO, the language preferred.
3.A: Mark NO to go to 3.B if there has been no change (for better or worse) in your medical condition(s) since you last told Social Security. If YES, enter the approximate date the change(s) occurred (MM/DD/YYYY) and describe the change(s) in detail.
3.B: Mark NO to go to 4.A if you have no new medical condition(s) since you last told Social Security. If YES, enter the approximate date and describe your new medical condition(s) in detail.
4.A: Mark YES to complete the chart(s) if, since you last told Social Security about your medical treatment, you have seen or received treatment from a healthcare provider or have a future appointment scheduled. Mark NO to go to 4.B.
Only list the healthcare providers you have seen since you last told Social Security about your medical treatment or are scheduled to see in the future. You may find this information on medical bills, online medical chart, or the Internet.
For each provider (4.A.1 to 4.A.4), enter the name of the facility or office, the name of the healthcare provider that treated you, and what medical conditions were treated or evaluated.
Enter the phone number, the dates first seen, last seen and of next appointment (if known) as MM/YYYY, and the address.
4.B: Since you last told Social Security about your medical treatment, did any of the healthcare providers listed in 4.A order any medical tests for you? Include tests performed and scheduled in the future. Mark NO to go to Section 5, or mark YES and select the tests from the chart.
For each test, enter the name of the healthcare provider or facility and the date of the test (MM/YYYY). For Biopsy, MRI/CT and X-ray, list body part. For Other, please specify.
5: Since you last told Social Security about your other medical information, does anyone else (other than your healthcare providers) have your medical information? Examples include Department of Veterans Affairs, attorneys, workers' compensation, and insurance companies who have paid you disability benefits. Mark NO to go to Section 6, or mark YES and complete the information.
If YES, enter the name of organization and phone number, address, name of contact person and claim number (if any), dates of first, last and next contact (if any), and reason(s) for contacts.
6: Are you currently taking any medicines (prescription or non-prescription)? Mark NO to go to Section 7, or mark YES and complete the information; you may need to look at your medicine containers.
For each medicine, enter its name, the reason (if known), the name of doctor if prescribed (if known), and side effects (if any).
7: Since you last told Social Security about your activities, has there been any change (for better or worse) in your daily activities due to your medical conditions? Mark NO to go to 8.A, or mark YES and describe these changes in detail.
8.A: Since you last told Social Security about your work, have you worked or has your work changed? Mark NO to go to 8.B, or mark YES and explain in detail. Social Security may ask you to provide additional information.
Provide any additional information you did not give in earlier parts of the report. If you did not have enough space in the sections of the report, use this space to provide the additional information requested in those sections.
If you need additional space, attach a separate sheet of paper(s). Be sure to include the section and question number to which you are referring.
Enter the date the report was completed (MM/DD/YYYY), then mark who is completing it: the person listed in 1.A, 2.A or 2.F, or someone else.
If someone else, enter the name, relationship to the person in 1.A, mailing address (street or PO Box) with apartment number, if applicable, and daytime phone number where you may be reached or can leave a message, if needed.
Answer every question unless the report indicates otherwise, and provide as much detail as possible.
If you do not know an answer, or the answer is none or does not apply, write don't know, none, or does not apply.
If you cannot remember the exact dates, provide the closest date you can remember.
If you need more space, or need to list more medicines, use Section 10, Remarks, on the last page.
Complete as much of the report as you can. You may be able to appeal online.
If you have internet access, you can locate your nearest Social Security office by ZIP code.
Anyone who makes or causes to be made a false statement or representation of material fact for use in determining a payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or continued right to payment, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be subject to administrative sanctions.
You can get help from other people, such as a friend or family member.
Do not ask your healthcare provider to complete the report.
If you cannot complete the report, you may contact Social Security at 1-800-772-1213, and a Social Security Representative will assist you.
[1] Form SSA-3441-BK (07-2026), Disability Report Appeal, Social Security Administration (the Official source link on this page).