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South Portland, ME
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Forms and Publications
| SOCIAL SECURITY DISABILITY | |||||
| Fillable / Saveable | |||||
| Forms and Publications | |||||
|
We make every effort to ensure our forms are correct and up-to-date. We would appreciate being notified of any errors or newer versions of forms by email to admin@ssdfacts.com. The Social Security Disability process is often confusing, and finding answers difficult. We hope to help simplify the process by providing you the necessary forms in a fillable/saveable/printable format. |
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| The publications available here are the same as those you will find at the Social Security website, and include all the forms you will receive from Social Security during the application process. They have been converted to a format that will allow you to type in the fields, make comments and print the forms for reference or submission. They include an auto-fill feature that will complete duplicate fields of the form with the previous information you entered. | |||||
| We have also converted many of the Social Security on-line Handbooks into pdf format so you can easily search for anything you might need. They have been "user-enabled", which allows yo to make comments and notes directly on the pdf and save for future reference. | |||||
| We have included a "How To" guide for those of you that might need more information on how to use these forms and handbooks to their fullest advantage. We truly hope they will help make the process of applying for disability easier for you. | |||||
| How to Use Forms and Publications at SSDFacts.com | |||||
| Browse Forms by Category | |||||
| Adult Application | Medicare | ||||
| Required Forms | General Information | ||||
| Optional Forms | Part B | ||||
| SSI Eligibility (Coming Soon) | Part D | ||||
| Child Application | On-Going Reviews | ||||
| Required Forms (Coming Soon) | Reporting Requirements | ||||
| Optional Forms (Coming Soon) | Continuing Disability Review | ||||
| Periodic Quality Review (Coming Soon) | |||||
| Reconsideration and Appeals | SSI Redetermination (Coming Soon) | ||||
| Reconsideration | Overpayment | ||||
| Administrative Law Judge | Termination/Reinstatement | ||||
| Appeals Council | |||||
| Employment | Post Approval | ||||
| Return to Work | General | ||||
| Expedited Reinstatement | Appointed Representative | ||||
| Ticket to Work | Representative Payee | ||||
| Plan for Self Sufficiency | Living Outside the U.S. | ||||
| Adult Disability Application | ||||||
| Required Forms and Related Publications | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| SSA-1170 | x | x | Actual Form | 6 | ||
| Adult Starter Kit | Used as Worksheet. Contains SSA-3381 and Checklist | |||||
| Chk-Adult | x | x | Actual Form | 1 | ||
| Checklist - Adult Disability Interview | Used as Worksheet | |||||
| SSA-3381 | x | x | Actual Form | 2 | Forms Page | |
| Medical and Job Worksheet - Adult | Used as Worksheet | |||||
| SSA-16-BK | x | Sample w/Fillable Fields | 7 | 20 | ||
| Application for Disability Insurance Benefits | ||||||
| SSA-16-iClaim (Coming Soon) |
x | Internet Submission | ||||
| Application for Disability Insurance Benefits | Screen shots of actual online application | |||||
| SSA-8000-BK | x | Actual Form | 21 | 40 | ||
| Application for Supplemental Security Income | ||||||
| SSA-827 | x | x | Actual Form | 1 | 10 | Forms Page |
| Authorization to Disclose Information | ||||||
| SSA-3368-BK | x | x | Actual Form | 14 | 60 | Forms Page |
| Disability Report - Adult | ||||||
| SSA-3368&69-iClaim (Coming Soon) |
x | Internet Submission | 57 | Periodic Quality Review | ||
| Disability & Work History Report - Adult | Screen shots of actual online application | |||||
| SSA-3369-BK | x | Actual Form | 10 | Forms Page | ||
| Work History Report | ||||||
| SSDIPkg (Coming Soon) |
x | Contains all SSDI application forms in one package. | ||||
| SSIPkg (Coming Soon) |
Contains all SSI application forms in one package. | |||||
| 05-10029 | x | Related Publication | Pub.05-10029 | |||
| Disability Benefits | ||||||
| 05-10032 | x | Related Publication | Pub.05-10032 | |||
| Apply Online For Social Security Benefits | ||||||
| 05-10072 | x | Related Publication | Pub.05-10072 | |||
| How You Earn Credits | ||||||
| 64-039 | x | x | Related Publication | Pub.64-039 | ||
| Disability Evaluation Under Social Security (Blue Book) | ||||||
| Optional Forms and Related Publications | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| SSA-795 | x | x | Actual Form | 1 | 15 | Forms Page |
| Statement of Claimant or Other Person | May be initiated by applicant or third-party to provide additional information. | |||||
| SSA-3373-BK | x | x | Actual Form | 10 | 61 | Forms Page |
| Function Report - Adult | DDS may request from Applicant | |||||
| SSA-3380-BK | x | x | Actual Form | 10 | 61 | Forms Page |
| Function Report - Adult - Third Party | DDS may request from Third Party | |||||
| SSA-521 | x | Actual Form | 2 | 5 | Forms Page | |
| Request for Withdrawal of Application | Initiated by Applicant to withdraw application | |||||
| SSA-104 | x | x | Sample Form | 5 | 10 | |
| Claimant Travel Reimbrusement Request | Mailed to Applicant by DDS when Consultive Exam (CE) is required | |||||
| SSA-91 | x | x | Sample Form | 1 | 5 | |
| Authorization to Release Medical Report to Physician | Applicant may request from SSA if he/she wishes to have a copy of the CE mailed to personal physician | |||||
| 05-10087 | x | x | Related Publication | Pub.05-10087 | ||
| A Special Examination Is Needed For Your Disability Claim | ||||||
| SSA-3826 | x | x | Sample Form | 4 | 30 | |
| Medical Report (General) | DDS may request from Medical Provider and/or Consultant | |||||
| SSA-4734-BK | x | x | Sample Form | 9 | 20 | |
| Physical Residual Functional Capacity Form | DDS may request from Medical Provider and/or Consultant | |||||
| SSA-824 | x | x | Sample Form | 3 | 36 | |
| Report on Individual with Mental Impairment | DDS may request from Medical Provider and/or Consultant | |||||
| SSA-4734-F4-SUP | x | x | Sample Form | 4 | 20 | |
| Mental Residual Functional Capacity Form | DDS may request from Medical Provider and/or Consultant | |||||
| SSA-392-SUP | x | x | Sample Form | 2 | 12 | |
| Medical Consultant's Review of Mental Residual Functional Capacity Assessment | Completed by Medical Consultant after review of sSA-4734-F4-SUP | |||||
| 64-025 | x | x | Related Publication | Pub.64-025 | ||
| Consultative Examinations - A Guide for Health Professionals | ||||||
| 64-042 | x | x | Related Publication | Pub.64-042 | ||
| Answers for Doctors & Other Health Professionals | ||||||
| 64-063 | x | x | Related Publication | Pub.64-063 | ||
| Providing Medical Evidence to the Social Security Administration for Individuals with Chronic Fatigue Syndrome | ||||||
| 64-092 | x | x | Related Publication | Pub.64-092 | ||
| HIPAA and the Social Security Disability Programs | ||||||
| 64-103 | x | x | Related Publication | Pub.64-103 | ||
| A Fact Sheet for Mental Health Care Professionals | ||||||
| 05-10052 | x | x | Related Publication | Pub.05-10052 | ||
| If You Are Blind Or Have Low Vision—How We Can Help | ||||||
| 05-10019 | x | x | Related Publication | Pub.05-10019 | ||
| Social Security For People Living With HIV/AIDS | ||||||
| 64-037 | x | x | Related Publication | Pub.64-037 | ||
| Providing Medical Evidence For Individuals With HIV Infection | ||||||
| VRPH | x | x | Related Publication | |||
| Vocational Rehabilitation Providers Handbook | ||||||
| SSA-4-BK | x | Sample w/Fillable Fields | 6 | 15 | ||
| Application for Child's Insurance Benefits | May be initiated by applicant to apply for Child's benefits | |||||
| SSA-2519 | x | Actual Form | 2 | 15 | Forms Page | |
| Child Relationship Statement | May be initiated by applicant to certify responsibility for Child living in a different household. | |||||
| SSA-781 | x | Actual Form | 2 | 10 | Forms Page | |
| Certificate of Responsibility for Welfare and Care of Child Not in Applicant's Custody | May be initiated by applicant to certify responsibility for Child living in a different household. | |||||
| 05-10085 | x | Related Publication | Pub.05-10085 | |||
| Benefits For Children | ||||||
| SSA-1696-U4 | x | x | Actual Form | 4 | 10 | Forms Page |
| Appointment of Representative | May be initiated by Applicant to appoint a representative for dealing with SSA | |||||
| SSA-1560-U4 | x | Actual Form | 2 | 30 | Forms Page | |
| Petition to Obtain Approval of a Fee for Representing a Claimant Before the SSA | Initiated by Appointed Representative to request approval of fee | |||||
| SSA-1695 | x | x | Actual Form | 2 | 10 | Forms Page |
| Identifying Information for Possible Direct Payment of Authorized Fees | Initiated by Appointed Representative to request direct deposit of fee | |||||
| SSA-1699 | x | x | Actual Form | 8 | 20 | Forms Page |
| Registration for Appointed Representative Services and Direct Payment | Initiated by Appointed Representative as authorization to do business with SSA (Not savable) | |||||
| 05-10075 | x | x | Related Publication | Pub.05-10075 | ||
| Your Right To Representation | ||||||
| SSA-308 | x | Actual Form | 2 | 10 | Forms Page | |
| Modified Benefit Formula Questionnaire-Foreign Pension | May be requested by SSA to report Foreign Pension | |||||
| SSA-21 | x | x | Actual Form | 4 | 10 | Forms Page |
| Supplement to Claim of Person Outside the United States | SSA may request from Applicant | |||||
| SSA-2490-BK | x | Sample Form (Fillable Fields) | 7 | 30 | ||
| Application for Benefits Under a U.S. International Social Security Agreement | Application to be used if living outside US | |||||
| 05-10017 | x | Related Publication | Pub.05-10017 | |||
| Military Service And Social Security | ||||||
| 05-10030 | x | Related Publication | Pub.05-10030 | |||
| Disability Benefits For Wounded Warriors | ||||||
| 05-10131 | x | Related Publication | Pub.05-10131 | |||
| Expediting Disability Applications For Wounded Warriors | ||||||
| SSA-150 | x | Actual Form | 2 | 8 | Forms Page | |
| Modified Benefit Formula Questionnaire | May be requested by SSA to report Windfall Elimination | |||||
| 05-10045 | x | Related Publication | Pub.05-10045 | |||
| Windfall Elimination Provision | ||||||
| SSA-546 | x | Actual Form | 2 | 12.5 | Forms Page | |
| Workers' Compensation/ :ublic Disability Benefit Questionnaire | May be requested by SSA to report Worker's Compensation and other public disability benefits | |||||
| SSA-1709 | x | Sample Form | 2 | 15 | ||
| Request for Worker's Compensation Public Disability Benefit Information | SSA may request from third-party to verify benefits. | |||||
| 05-10018 | x | Related Publication | Pub.05-10018 | |||
| How Workers' Compensation and Other Disability Payments May Affect Your Benefits | ||||||
| SSA-766 | x | Sample Form | 1 | 5 | ||
| Statement of Self-Employment Income | SSA may request from self-employed applicant to establish minimum quarters of coverage | |||||
| 05-10022 | x | Related Publication | 1 | 5 | Pub.05-10022 | |
| If You Are Self-Employed | ||||||
| Supplemental Security Income (SSI) Eligibility | ||||||
| (Coming Soon) | ||||||
| Child Disability Application | ||||||
| (Coming Soon) | ||||||
| Reconsideration and Appeal | ||||||
| Reconsideration | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| SSA-561-U2 | x | x | Actual Form | 2 | 8 | Form.SSA-561-U2 |
| Request For Reconsideration | Initiated by Applicant to request reconsideration of disability decision | |||||
| SSA-561-i/SSA-3441-i | x | x | Internet Submission | 17 | 20 | |
| Request For Reconsideration & Disability Report | Initiated by Applicant to request reconsideration of disability decision. Internet version combines two paper forms | |||||
| SSA-3441-BK | x | x | Actual Form | 10 | 45 | Form.SSA-3441-BK |
| Disability Report - Appeal | Initiated by applicants / beneficiaries appealing disability determination, requesting hearing before hearing officer or ALJ | |||||
| 05-10058 | x | x | Related Publication | Pub.05-10058 | ||
| Your Right To Question The Decision Made On Your Claim | ||||||
| 05-10041 | x | x | Related Publication | Pub.05-10041 | ||
| The Appeals Process | ||||||
| Administrative Law Judge (ALJ) | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| HA-501-U5 | x | x | Actual Form | 2 | 10 | |
| Request For Hearing By Administrative Law Judge | Initiated by applicant / beneficiary to request hearing before ALJ | |||||
| HA-501-I/SSA-3441-I | x | x | Internet Submission | 30 | 20 | |
| Request For Hearing By Administrative Law Judge & Disability Report | Initiated by applicant / beneficiary to request hearing before ALJ. Internet version combines two paper forms | |||||
| SSA-769-U4 | x | x | Sample Form | 1 | 15 | |
| Request For Change In Time/Place Of Disability Hearing | Initiated by Applicant or Beneficiary to request change of hearing. | |||||
| SSA-3441-BK | x | x | Actual Form | 10 | 45 | |
| Disability Report - Appeal | May be requested from applicants / beneficiaries appealing disability determination, requesting hearing before hearing officer or ALJ | |||||
| HA-4631 | x | x | Actual Form | 2 | 10 | Form.HA-4631 |
| Claimant's Recent Medical Treatment | May be requested from claimant to update medical record | |||||
| HA-4632 | x | x | Actual Form | 2 | 15 | Form.HA-4632 |
| Claimant's Medications | May be requested from claimant to update medical record | |||||
| HA-4633 | x | x | Actual Form | 2 | 15 | Form.HA-4633 |
| Claimant's Work Background | May be requested from claimant to update work history | |||||
| HA-1151 | x | x | Sample Form | 9 | 15 | |
| Medical Source Statement Of Ability To Do Work-Related Activities (Physical) | May be requested from Medical Provider or Consultant | |||||
| HA-1152 | x | x | Sample Form | 5 | 15 | |
| Medical Source Statement Of Ability To Do Work-Related Activity (Mental) | May be requested from Medical Provider or Consultant | |||||
| HA-4608 | x | x | Actual Form | 2 | 2 | Form.HA-4608 |
| Waiver Of Your Right To Personal Appearance Before An Administrative Lawjudge | May be initiated by Applicant | |||||
| HA-504 | x | x | Sample Form | 2 | 1 | |
| Acknowledgement Of Receipt (Notice Of Hearing) | Issued to claimant to acknowledge notice of hearing. | |||||
| HA-504-OP1 | x | x | Sample Form | 2 | 1 | |
| Acknowledgement Of Receipt (Notice Of Hearing) | Issued to claimant to acknowledge notice of hearing. | |||||
| SSA-525 | x | x | Sample Form (Fillable) | 2 | 30 | |
| Request To Decision Review Board To Vacate The Administrative Law Judge Dismissal Of Hearing | Initiated by Claimant to request dismissal of ALJ be vacated. | |||||
| 70-10281 | x | x | Related Publication | Pub.70-10281 | ||
| Your Right To An Administrative Law Judge Hearing And Appeals Council Review Of Your Social Security Case | ||||||
| 70-067 | x | x | Related Publication | Pub.70-067 | ||
| Why You Should Have Your Hearing By Video | ||||||
| Appeals Council | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| HA-520-U5 | x | x | Actual Form | 2 | 10 | Form.HA-520-U5 |
| Request For Review Of Hearing Decision/Order | Initiated by Applicant | |||||
| HA-539 | x | x | Actual Form | 2 | 5 | Form.HA-539 |
| Notice Regarding Substitution Of Party Upon Death Of A Claimant | Inititiated by individual to substitute for deceased claimant. | |||||
| HA-66 | x | x | Sample Form | 2 | 15 | |
| Request For Evidence From Doctor | May be requested from Medical Provider | |||||
| HA-67 | x | x | Sample Form | 2 | 15 | |
| Request For Evidence From Hospital | May be requested from hospitals | |||||
| 70-10281 | x | x | Related Publication | Pub.70-10281 | ||
| Your Right To An Administrative Law Judge Hearing And Appeals Council Review Of Your Social Security Case | ||||||
| Employment | ||||||
| Return to Work | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| SSA-820-F4 | x | x | Actual Form | 4 | 30 | Forms Page |
| Work Activity Report (Self-Employed Person) | SSA may request from beneficiary to determine if work performed in self-employment is at SGA level. | |||||
| SSA-821-BK | x | x | Actual Form | 9 | 45 | Forms Page |
| Work Activity Report — Employee | SSA may request from beneficiary to determine if work performed is at SGA level. | |||||
| SSA-L725 | x | x | Sample Form | 2 | 40 | |
| Letter To Employer Requesting Information About Wages Earned | SSA may request from Employer to determine monthly benefits | |||||
| SSA-131 | x | x | Actual Form | 2 | 20 | Forms Page |
| Employer Report Of Special Wage Payments | SSA may request from Employer to verify special wages | |||||
| SSA-3033 | x | x | Actual Form | 3 | 15 | Forms Page |
| Employee Work Activity Report | SSA may request from Employer when return to work has been unsuccessful. | |||||
| 05-10069 | x | x | Related Publication | Pub.05-10069 | ||
| How Work Affects Your Benefits | ||||||
| 05-10095 | x | x | Related Publication | Pub.05-10095 | ||
| Working While Disabled - How We Can Help | ||||||
| 05-10052 | x | x | Related Publication | Pub.05-10052 | ||
| If You Are Blind Or Have Low Vision—How We Can Help | ||||||
| 64-030 | x | x | Related Publication | Pub.Redbook | ||
| Red Book | ||||||
| Expedited Reinstatement | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| SSA-371&372 | x | x | Sample Letter | 4 | ||
| Cover Letter | Issued by SSA to transmit SSA-371/372 for after unsuccessful return to work | |||||
| SSA-371 | x | Sample Form (Fillable Fields) | 2 | 2 | ||
| Request For Reinstatement (Title II) | Initiated by former SSDI recipient to request expedited reinstatement | |||||
| SSA-372 | x | Sample Form (Fillable Fields) | 2 | |||
| Request For Reinstatement (Title XVI) | Initiated by former SSI recipient no longer performing SGA | |||||
| SSA-454-BK | x | x | Sample Form | 16 | 60 | |
| Continuing Disability Review Report | Required to be submited with SSA-371 or SSA-372 | |||||
| SSA-454-ICR | x | x | Sample Form | 9 | 30 | |
| Continuing Disability Review Report | Required to be submited with SSA-371 or SSA-372 | |||||
| SSA-827 | x | x | Actual Form | 1 | 10 | Forms Page |
| Authorization to Disclose Information | ||||||
| Ticket to Work | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| SSA-1370 (Coming Soon) |
x | x | Sample Form | 3 | 60 | |
| Ticket To Work Individual Work Plan | ||||||
| SSA-1375 (73&74) (Coming Soon) |
x | x | Sample Form | 4 | 15 | |
| Ticket To Work Progress Review Form | ||||||
| SSA-L1377 (Coming Soon) |
x | x | Sample Form | 3 | 15 | |
| Employer Progress Review | ||||||
| 05-10061 | x | x | Related Publication | Pub.05-10061 | ||
| Your Ticket To Work | ||||||
| 05-10062 | x | x | Related Publication | Pub.05-10062 | ||
| Your Ticket To Work - What You Need To Know To Keep It Working For You | ||||||
| 05-10060 | x | x | Related Publication | Pub.05-10060 | ||
| The Ticket To Work Program And Other Work Incentives | ||||||
| 05-10065 | x | x | Related Publication | Pub.05-10065 | ||
| Employment Networks In Social Security'S Ticket To Work Program | ||||||
| SSA-1365 | x | x | Actual Form | 2 | 3 | TheWorkSite |
| State Agency Ticket Assignment Form Ticket To Work And Self-Sufficiency Program | Initiated by beneficiary wishing to assign Ticket to Work to a State VR program | |||||
| SSA-4290 (Coming Soon) |
x | x | Sample Form | 4 | 15 | |
| Development Of Participation In A Vocational Rehabilitation Or Similar Program | Completed by State VR programs to document beneficiary's participation in VR program | |||||
| Plan To Achieve Self-Support (PASS) | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| SSA-545-BK (Coming Soon) |
x | Actual Form | 14 | 120 | ||
| Plan To Achieve Self-Support | ||||||
| 05-11017 | x | Related Publication | Pub.05-11017 | |||
| Working While Disabled—A Guide To Plans For Achieving Self-Support | ||||||
| 64-104 | x | Related Publication | Publications | |||
| A Guide To Preparation Of The Plan To Achieve Self-Support (Pass) Application FormFor People Who Are Blind Or Visually Impaired | ||||||
| Medicare | ||||||
| General Information | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| 05-10043 | x | Related Publication | Pub.05-10043 | |||
| Medicare | ||||||
| 05-10024 | x | Related Publication | Pub.05-10024 | |||
| Understanding The Benefits | ||||||
| CMS-10050 | x | Related Publication | CMS-10050 | |||
| Medicare & You | ||||||
| 05-10020 | x | Related Publication | Pub.05-10020 | |||
| Important Information For Tricare (Military Health Benefits) Beneficiaries Entitled To Medicare Based On Social Security Disability | ||||||
| Part B | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| SSA-44 | x | Actual form | 8 | Forms Page | ||
| Medicare Part B Income-Related Premium - Life-Changing Event | Initiated by enrollee when life-changing event may reduce payment | |||||
| SSA-44-I | x | Interview | 6 | |||
| Medicare Part B Income-Related Premium - Life-Changing Event | Initiated by enrollee when life-changing event may reduce payment | |||||
| SSA-4640 | x | Sample Form (Fillable) | 2 | 5 | ||
| Authorization For Ssa To Obtain Account Records From A Financial Institution And Request For Records (Medicare) (As Completed By The Claimant.) | SSA may request for Third-Party Verification | |||||
| SSA-54 | x | Actual Form | 2 | 15 | Forms Page | |
| Authorization For Ssa To Disclose Tax Information For Your Appeal Of Your Medicare Part B Income-Related Monthly Adjustment Premium Amount | SSA may request for Third-Party Verification | |||||
| 05-10162 | x | Related Publication | Pub.05-10162 | |||
| Medicare Part B Premiums - Important Information For People Newly Eligible For Medicare | ||||||
| 05-10536 | x | Related Publication | Pub.05-10536 | |||
| Medicare Part B Premiums: Rules For Beneficiaries With Higher Incomes | ||||||
| 05-10116 | x | Related Publication | Pub.05-10116 | |||
| Medicare Part B Premiums - Rules For Beneficiaries With Higher Incomes FAQ | ||||||
| 05-10125 | x | Related Publication | Pub.05-10125 | |||
| Medicare Part B Premiums - What You Can Do If You Think Your Medicare Part B Income-Related Premium Is Incorrect | ||||||
| 05-10507 | x | Related Publication | Pub.05-10507 | |||
| Medicare Annual Verification Notices: Frequently Asked Questions | ||||||
| Part D | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| SSA-1020B-INST | x | Sample Form | 8 | 30 | Forms Page | |
| Application For Help With Medicare Prescription Drug Plan Costs | ||||||
| SSA-1020-i (Coming Soon) |
x | Internet Submission | 50 | 24?? | ||
| Application For Help With Medicare Prescription Drug Plan Costs | ||||||
| SSA-1021 | x | Actual Form | 4 | 10 | Forms Page | |
| Appeal Of Determination For Extra Help With Medicare Prescription Drug Plan Costs | ||||||
| SSA-1021-i (Coming Soon) |
x | Interview | 4 | |||
| Appeal Of Determination For Extra Help With Medicare Prescription Drug Plan Costs (Interview) | ||||||
| 05-10040 | x | Related Publication | Pub.05-10040 | |||
| Changes In The Law Could Make More People Eligible For Extra Help In 2010 | ||||||
| 05-10115 | x | Related Publication | Pub.05-10115 | |||
| Getting Extra Help With Medicare Prescription Drug Plan Costs - Resource And Income Limits | ||||||
| 05-10118 | x | Related Publication | Pub.05-10118 | |||
| Getting Extra Help With Medicare Prescription Drug Plan Costs. Information For Medicare Beneficiaries With Disabilities | ||||||
| 05-10122 | x | Related Publication | Pub.05-10122 | |||
| Tips For Completing The Application For Extra Help With Medicare Prescription Drug Plan Costs | ||||||
| 05-10128 | x | Related Publication | Pub.05-10128 | |||
| What You Need To Complete The Application For Extra Help With Medicare Prescription Drug Plan Costs | ||||||
| 05-10144 | x | Related Publication | Pub.05-10144 | |||
| Your Right To Question The Decision On Your Application For Help With Medicare Prescription Drug Plan Costs | ||||||
| 05-10505 | x | Related Publication | Pub.05-10505 | |||
| Help Someone Save An Average Of $3,900 On Prescription Drug Costs | ||||||
| 05-10508 | x | Related Publication | Pub.05-10508 | |||
| Understanding The Extra Help With Your Medicare Prescription Drug Plan | ||||||
| 05-10524 | x | Related Publication | Pub.05-10524 | |||
| It'S Easier Than Ever To Save On Your Prescription Costs | ||||||
| 05-10525 | x | Related Publication | Pub.05-10525 | |||
| Medicare Part D Extra Help | ||||||
| SSA-1026-OCR-SM | x | Sample Form | 10 | 18 | ||
| Social Security Administration Review Of Your Eligibility For Extra Help | Periodic Quality Review | |||||
| SSA-8510 (Coming Soon) |
x | Sample Form | 1 | 10 | ||
| Authorization For The Social Security Administration To Obtain Personal Information | Periodic Quality Review | |||||
| 05-10111 | x | Related Publication | ||||
| Review Of Your Eligibility For Extra Help With Medicare Prescription Drug Plan Costs: Some Things You Should Know | ||||||
| On-Going Reviews | ||||||
| Reporting Requirements | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| SSA-1425 | x | x | Sample Form (Fillable) | 2 | 5 | |
| Reporting Changes That Affect Your Social Security Payment | ||||||
| SSA-612 | x | Sample Form | 2 | 5 | ||
| Report Of New Information In Disability Cases | ||||||
| SSA-8150-EV (Coming Soon) |
x | Sample Form | 1 | 5 | ||
| Reporting Events, Ssi | ||||||
| SSA-1372-BK (Coming Soon) |
x | Actual Form | 7 | 3 | ||
| Advance Notice Of Termination Of Child's Benefits | Issued in advance of child turning 18 to determine eligibility for Student Benefits | |||||
| SSA-1383 (Coming Soon) |
x | Sample Form | 2 | 6 | ||
| Student Reporting Form | ||||||
| 05-10503 | x | Related Publication | Pub.05-10503 | |||
| Reporting Your Wages When You Receive Supplemental Security Income (SSI) | ||||||
| 05-10501 | x | Related Publication | Pub.05-10501 | |||
| Monthly Wage Reporting And Supplemental Security Income (SSI) For Sheltered Workshops | ||||||
| Continuing Disability Review (CDR) | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| SSA-454-BK | x | x | Sample Form | 16 | 60 | |
| Continuing Disability Review Report | Required of all beneficiaries when their reexamination is due. | |||||
| SSA-454-ICR | x | x | Sample Form | 9 | 30 | |
| Continuing Disability Review Report | The paper BK version is slowly being phased out and replaced by this IRC version | |||||
| SSA-455-OCR-SM | x | x | Sample Form | 4 | 15 | |
| Disability Update Report | SSA-455 is slowly being phased out and replaced by this OCR version | |||||
| 05-10068 | x | x | Related Publication | Pub.05-10068 | ||
| What You Need To Know - Reviewing Your Disability | ||||||
| 05-10053 | x | x | Related Publication | Pub.05-10053 | ||
| How We Decide If You Are Still Disabled | ||||||
| 64-039 | x | x | Related Publication | BlueBook | ||
| Disability Evaluation Under Social Security (Blue Book) | ||||||
| SSA-3373-BK | x | x | Actual Form | 10 | 61 | Forms Page |
| Function Report - Adult | DDS may request from Applicant | |||||
| SSA-4734-BK | x | x | Sample Form | 9 | 20 | |
| Physical Residual Functional Capacity Form | DDS may request from Medical Provider and/or Consultant | |||||
| SSA-4734-F4-SUP | x | x | Sample Form | 4 | 20 | |
| Mental Residual Functional Capacity Form | DDS may request from Medical Provider and/or Consultant | |||||
| SSA-104 | x | x | Sample Form | 5 | 10 | |
| Claimant Travel Reimbrusement Request | Mailed to Applicant by DDS when Consultive Exam (CE) is required | |||||
| SSA-392-SUP | x | x | Sample Form | 2 | 12 | |
| Medical Consultant's Review of Mental Residual Functional Capacity Assessment | Completed by Medical Consultant after review of sSA-4734-F4-SUP | |||||
| SSA-91 | x | x | Sample Form | 1 | 5 | |
| Authorization to Release Medical Report to Physician | Applicant may request from SSA if he/she wishes to have a copy of the CE mailed to personal physician | |||||
| 05-10087 | x | x | Related Publication | Pub.05-10087 | ||
| A Special Examination Is Needed For Your Disability Claim | ||||||
| 64-025 | x | x | Related Publication | Green Book | ||
| Consultative Examinations - A Guide for Health Professionals | ||||||
| 64-042 | x | x | Related Publication | Pub.64-042 | ||
| Answers for Doctors & Other Health Professionals | ||||||
| 64-063 | x | x | Related Publication | Pub.64-063 | ||
| Providing Medical Evidence to the Social Security Administration for Individuals with Chronic Fatigue Syndrome | ||||||
| 64-092 | x | x | Related Publication | Pub.64-092 | ||
| HIPAA and the Social Security Disability Programs | ||||||
| 64-103 | x | x | Related Publication | Publications | ||
| A Fact Sheet for Mental Health Care Professionals | ||||||
| SSA-832-C3-U3 | x | x | Sample Form | 2 | 30 | |
| Cessation Or Continuance Of Disability Or Blindness Determination And Transmittal | Completed by state DDS to document determination of continued eligibility | |||||
| 05-10090 | x | x | Related Publication | Pub.05-10090 | ||
| Your Right To Question The Decision To Stop Your Disability Benefits | ||||||
| 05-10041 | x | x | Related Publication | Pub.05-10041 | ||
| The Appeals Process | ||||||
| 64-048 | Child | Related Publication | ||||
| Childhood Disability-SSI Program - Guide for Physicians | ||||||
| 64-049 | Child | Related Publication | ||||
| Childhood Disability-SSI Program - Guide for School Professionals | ||||||
| Periodic Quality Review | ||||||
| (Coming Soon) | ||||||
| SSI Redetermination | ||||||
| (Coming Soon) | ||||||
| Overpayment | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| SSA-3105 | x | x | Sample Form (Fillable) | 2 | ||
| Important Information About Your Appeal, Waiver Rights, And Repayment Options | Initiated by SSA describing beneficiary's rights. | |||||
| SSA-632-BK | x | x | Actual Form | 8 | 120 | Form.SSA-632 |
| Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate | Initiated by Beneficiary to contest overpayment. | |||||
| 05-10098 | x | x | Related Publication | Pub.05-10098 | ||
| Overpayments | ||||||
| Termination / Reinstatement | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| SSA-765 | x | x | Sample Form | 2 | 30 | |
| Response To Notice Of Revised Determination | Initiated by recipient in response to notice of disability cessation. Must be requested from SSA. | |||||
| SSA-770 | x | x | Sample Form | 1 | 5 | |
| Notice Regarding Substitution Of Party Upon Death Of Claimant--Reconsideration Of Disability Cessation | Initiated by substitute party on behalf of deceased recipient to request reconsideration of disabilitycessation. | |||||
| SSA-789-U4 | x | x | Actual Form | 1 | 15 | Forms Page |
| Request For Reconsideration - Disability Cessation | ||||||
| SSA-3441-BK | x | x | Actual Form | 10 | 45 | Form.SSA-3441 |
| Disability Report - Appeal | May be requested from applicants / beneficiaries appealing disability determination, requesting hearing before hearing officer or ALJ | |||||
| SSA-3441-I | x | x | Internet Submission | 17 | 120 | |
| Disability Report - Appeal (Internet) | May be requested from applicants / beneficiaries appealing disability determination, requesting hearing before hearing officer or ALJ | |||||
| SSA-769-U4 | x | x | Sample Form (Fillable) | 1 | 15 | |
| Request For Change In Time/Place Of Disability Hearing | Initiated by Applicant or Beneficiary to request change of hearing. | |||||
| SSA-773 | x | x | Sample Form (Fillable) | 1 | 3 | |
| Waver Of Right To Appear--Disability Hearing | Initiated by Applicant or Beneficiary. | |||||
| 05-10058 | x | x | Related Publication | Pub.05-10058 | ||
| Your Right To Question The Decision Made On Your Claim | ||||||
| Post Approval | ||||||
| General | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| 05-10153 | x | Related Publication | Pub.05-10153 | |||
| What You Need To Know When You Get Social Security Disability Benefits | ||||||
| 05-11011 | x | Related Publication | Pub.05-11011 | |||
| What You Need To Know When You Get Supplemental Security Income (SSI) | ||||||
| 1199-A | x | x | Actual Form | 4 | 10 | Forms Page |
| Direct Deposit Sign-Up Form | ||||||
| 05-10073 | x | x | Related Publication | Pub.05-10073 | ||
| Get Your Payment Through The Direct Express Card | ||||||
| 05-10028 | x | x | Related Publication | Pub.05-10028 | ||
| Moving? Save Time - Change Your Address Online | ||||||
| SSA-3288 | x | x | Actual Form | 2 | 3 | Forms Page |
| Consent For Release Of Information | May be used to request personal records through FOIA | |||||
| SSA-117-PC | x | x | Actual Form | 1 | 5 | Forms Page |
| How Are We Doing? | ||||||
| SSA-437-BK | x | x | Actual Form | 8 | 60 | Forms Page |
| Complaint Form For Allegations Of Discrimination In Programs Or Activities Conducted By The Social Security Administration | ||||||
| 05-10071 | x | x | Related Publication | Pub.05-10071 | ||
| How To File An Unfair Treatment Complaint | ||||||
| 05-10100 | x | Related Publication | Pub.05-10100 | |||
| Food Stamps And Other Nutrition Programs | ||||||
| 05-10101 | x | Related Publication | Pub.05-10101 | |||
| Food Stamp Facts | ||||||
| Appointed Representative | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| 05-10075 | x | x | Related Publication | Pub.05-10075 | ||
| Your Right To Representation | ||||||
| SSA-1696-U4 | x | x | Actual Form | 4 | 10 | Form.SSA-1696 |
| Appointment of Representative | May be initiated by Applicant to appoint a representative for dealing with SSA | |||||
| SSA-1560-U4 | x | Actual Form | 2 | 30 | Form.SSA-1560 | |
| Petition to Obtain Approval of a Fee for Representing a Claimant Before the SSA | Initiated by Appointed Representative to request approval of fee | |||||
| SSA-1695 | x | x | Actual Form | 2 | 10 | Forms Page |
| Identifying Information for Possible Direct Payment of Authorized Fees | Initiated by Appointed Representative to request direct deposit of fee | |||||
| SSA-1699 | x | x | Actual Form | 8 | 20 | Forms Page |
| Registration for Appointed Representative Services and Direct Payment | Initiated by Appointed Representative as authorization to do business with SSA (Not savable) | |||||
| Payee Representative | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| 05-10097 | x | x | Related Publication | Pub.05-10097 | ||
| When A Representative Payee Manages Your Money | ||||||
| 05-10076 | x | Related Publication | Pub.05-10076 | |||
| A Guide For Representative Payees | ||||||
| SSA-11-BK | x | x | Actual Form | 10 | 10.5 | Forms Page |
| Request To Be Selected As Payee | ||||||
| SSA-11-BK-I | x | x | Interview | 151 | ||
| Request To Be Selected As Payee - Interview | ||||||
| SSA-788-F4 | x | x | Sample Form | 4 | 10 | |
| Statement Of Care And Responsibility For Beneficiary | ||||||
| SSA-787 | x | x | Actual Form | 2 | 10 | Forms Page |
| Physician'S/Medical Officer'S Statement Of Patient'S Capability To Manage Benefits | ||||||
| SSA-322 | x | x | Sample Form | 10 | 15 | |
| Beneficiary Interview & Auditor'S Observations | Randomly selected interview of beneficiaries to determine if payee is properly complying with responsibilities | |||||
| SSA-637 | x | x | Sample Form | 22 | 120 | |
| Expanded Monitoring Site Review Questionnaire For Volume And Fee For Service Payees | Randomly selected audit of representive payees | |||||
| SSA-639 | x | x | Sample Form | 4 | 10 | |
| Expanded Monitoring Site Review Beneficiary Review Form | Randomly selected audit of representive payees | |||||
| Living Outside the U.S. | ||||||
| Form / Publication | Applies To | Form Type / Description | Pages | Est. Time | Found at SSA Website | |
| SSDI | SSI | |||||
| 05-10137 | x | x | Pub.05-10137 | |||
| Your Payments While You Are Outside The United States | ||||||
| SSA-7163 | x | x | Actual Form | Forms Page | ||
| Questionnaire About Employment Or Self-Employment Outside The United States | ||||||
| SSA-7161-OCR-SM | x | x | Actual Form | 2 | 15 | |
| Report To United States Social Security Administration By Person Receiving Benefits For A Child Or An Adult Unable To Handle Funds | To monitor Payee Representatives living outside United States | |||||
| SSA-7162-OCR-SM | x | x | Sample Form (Fillable) | 2 | ||
| Report To The United States Social Security Administration | To determinine continuing eligibility while living outside U.S. | |||||
| SSA-21 | x | x | Sample Form | 4 | 10 | |
| Supplement to Claim of Person Outside the United States | SSA may request from Applicant | |||||
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