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.

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.

 

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
  Child Disability Report       Reporting Requirements
          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
Child Disability Report 
Form / Publication Applies To Form Type / Description Pages Est. Time Found at SSA Website
SSDI SSI
SSA-3280

 Child Disability Report

  x         Actual Form            To be completed after intial SSI Application 12   Form SSA-3280
     
SSA-3280-i   x Internet Submission 12    
Child Disability Report Online  

SSA-3280 Online

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

Form.HA-501-U5

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
  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
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
   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
  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