Form i561 (Internet Ver i561 (Internet Ver Request for Reconsideration

iAppeals Screens for the final PSA (May 24)

5

Welcome!
This is the starting point to request a review of our medical decision about
your eligibility for disability benefits. There are two parts to this Internet
Appeal process: (1) an Appeal Request form; and (2) an Appeal Disability
Report that gives us more information about your condition. You can
complete both forms online. To appeal online, you may submit only an
appeal request (Part 1). We are asking you to also submit an Appeal
Disability Report (Part 2) because it will give us more information about you
and help us in processing your appeal. If you do not want to use the
Internet to request your appeal, there are Other Ways to Request an Appeal
or Complete a Disability Report.
NOTE: We use the term “claimant” to refer to the adult or child whose
disability decision is being appealed.
To be able to use this Internet process, the claimant must:
Have applied for benefits
Have received a “Notice of Disapproved Claim”, a “Notice of
Reconsideration”, or “Notice of Federal Reviewing Official Decision”, and
have the notice available when beginning this process. (If you do not
know which notice you received, refer to About Your Notice.)
Disagree with the disability decision
Live in the United States or one of its territories
If any of the above statements are not true, stop here
and contact Social Security!
Completing the Internet Appeal Process
The first part of your appeal is the Appeal Request. The next five pages
explain this request and help you get ready to provide the information we
need. The sixth page is the Appeal Request form. We will ask you to
provide information about your representative if you have one. You will be
able to review the information you provide before sending it to us
electronically. The Appeal Request is a short form and you must complete
and submit it in a single session. You will not be able to come back to it
later.
Part 2 of the two-part Internet process is completing the Appeal Disability
Report. We will walk you through completion of this report right after you
submit the Appeal Request. The Report asks you to tell us about any
changes that have occurred since the claimant last completed a disability
report. This includes information about the claimant’s condition, doctors or
other medical sources and treatment, work activity and education. You do
not have to complete this report all at once. Later we will tell you how to
return to an Appeal Disability Report that you had started earlier.
To start the Internet Appeal Request and Disability Report process,
select this button.
Start the Appeal
Already started an Appeal Disability Report? Then select this button.
Go Back to the Report I Already Started

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.
More Information about Disability and the Appeal Process
How the Disability Appeals Process Works
Your Right to Representation
Social Security’s Definition of Disability for Adults
Social Security’s Definition of Disability for Children
Internet Security Policy
Social Security’s Accessibility Policy
Privacy Information
Information about Social Security’s Disability Programs
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iAppeals Screens for the final PSA (May 24)

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About This Internet Appeal Process

Using Social Security Online Services
Using the Internet Appeal Request and Disability Report gives you:
Security and privacy for your information.
Step by step instructions and examples to help you complete the
Appeal Request and the Disability Report.
A process to collect information that applies to you, similar to the
interview process in a Social Security Office.
The ability to work at your own pace, stopping when you want and
coming back to finish later.
What You Will Need
The Internet Appeal Request and Disability Report process asks for
information about the adult or child whose disability decision is being
appealed (the “Claimant”) and his or her medical history.
For us to decide that the Claimant is disabled under the Social
Security Act and its regulations, you must give us as much
information as possible so that we can contact your doctors and
hospitals directly to get your medical records. It is important that you
give us the names, addresses, and dates of treatment for all your
doctors and hospitals. The list below provides details about what you
will need.
For Part 1: The Appeal Request
Your Social Security Number, name, address, and telephone
number, if you have one.
Your Notice of Decision.
Information about your Representative, if you have one. Use this
link for more information about having a Representative.
For Part 2: The Disability Report
The name, address including ZIP code, and telephone number of
someone else who knows about your illnesses, injuries and
conditions (referred to only as conditions from here on) and can
give us information about you. (Note: The instructions page for
Part 2 provides a link for ZIP code lookup, if you need it.)
A description of any changes in your conditions since you last
completed a disability report, including new physical and mental
limitations and new conditions.
The names, addresses including ZIP codes, and telephone
numbers for all doctors, hospitals, and clinics that you have seen
since you last completed a disability report, and the dates you
saw them.
The name of each medical test that you have had since you last
completed a disability report, when and where the test was done,
and who ordered it.
The name of each current prescription and over-the-counter
medicine that you take and the doctor who prescribed it.
Other Information
Third Party Links: Some Social Security Online pages contain links to
third party sites not operated by SSA. Those sites are not within our
control and may not follow the same privacy, security, or accessibility
standards as ours. We are not responsible for the content or availability
of those sites, their partners, or advertisers.
Previous Page

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iAppeals Screens for the final PSA (May 24)

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Should You Use This Internet Appeal Process?
Not everyone will be able to complete this process online. You must
answer all of the following questions to help us determine if you should
use this Internet process or if it would be better for you to speak with a
Social Security representative.
Do you live in the
United States or one
of its territories/
commonwealths?

Yes

No

Did you receive a
notice of decision?

Yes

No

Continue

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iAppeals Screens for the final PSA (May 24)

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About Your Appeal

Thank you and welcome to the Internet Appeal Request.
Please answer the following questions to help us determine how to
guide you through the Internet Appeal process. If you are unsure of the
answers to any of these questions, please contact Social Security for
assistance.

Suffix (if any)

Claimant Name:
(Enter the First, Middle, and
Last Name of the person
applying for benefits.)

Claimant Social
Security Number:
Please enter the Social
Security Number without
dashes or hyphens.

Claimant date of
birth:
What is the date on
the “Notice of
Decision” you
received?
(If you do not know which
date we are referring to,
see What Is My Notice
Date?)

Continue

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iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

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OMB No. 0960-0622

About the Request For Reconsideration

FIRST APPEAL: The letter you received about our determination on
your case tells you about your right to request a reconsideration of our
determination on your case. To request this review, you need to
complete an SSA-561-U2, Request for Reconsideration. The next few
pages allow you to electronically complete and submit the SSA-561.
The last page of Part 1 is a Receipt page with a date and time
confirmation that you should print and save for your records.
EVIDENCE: You should mail any information you have that shows our
original determination was not correct to the Social Security office
address provided at the end of Part 2. You should also complete the
SSA-3441, Disability Report - Appeal, and complete, sign and date the
SSA-827, Authorization to Disclose Information to SSA. The Appeal
Disability Report (SSA-3441) is Part 2 of this Internet Appeal process,
and it includes a link to the SSA-827.
You may also need to complete a form SSA-1696, Appointment of
Representative, if you are appointing a representative. If your
representative is not an attorney, he or she must sign the SSA-1696 or
state in writing that he or she accepts the appointment, before you send
it to us. Both the Appeal Request Receipt page and the Appeal
Disability Report include a link to the SSA-1696.
If you have questions, you may call our toll-free number, 1-800-7721213, (for people who are deaf or hard of hearing, call our 'TTY' number,
1-800-325-0778), or contact your local Social Security Office. If you
contact us, please be sure to have in your possession any letters we
sent you. It will help us answer your questions.
We estimate you will need 18 minutes to complete this Request for
Reconsideration. If you want more information, use this link to read
about the Paperwork Reduction Act.
If you want to file your request for review online, please select the
Continue button to go to the next page. If you choose not to complete
your request online, please select the Exit button to leave this appeal
process.
Continue

Exit

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iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

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Request For Reconsideration

Please enter your Appeal Request information.
Name of Claimant

John Public

(First, Middle, Last)

Claimant’s Mailing
Address:
Please provide a complete address, including apartment number if applicable. Please do NOT
use punctuation; for example, no periods or commas. Example: 528 Dawn St Apt 101
(Street Line 1)
(Street Line 2)
(City, State, Zip Code)

Claimant Telephone
Number:
Example: (111) 222-3333

Wage Earner Name (if
different from Claimant):
(First, Middle, Last)

Suffix (if any)

Who is the Wage Earner?

Claimant Social Security
Number (SSN)

xxx-xx-1234

Claimant Claim Number
(if different from SSN):
What is the Claim Number?

Supplemental Security
Income (SSI) Claim
Number:
What is the Claim Number?

I do not agree with the determination made on the above claim and request reconsideration.
My reasons are:
205 characters
maximum. This is
about 4 lines of
typing.
Count Characters

Do you currently have
a representative?
Select one:

Yes

No

I am completing this form as the Claimant.
I am completing this form as the Claimant’s Representative.

Select the Continue button to review your information before sending it
to the Social Security Administration. Select the Previous Page button
if you want to review the previous page of instructions.
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iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

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Submit Your Request For
Reconsideration (Filed By Claimant)
Please review your Request for Reconsideration information below before
sending it to the Social Security Administration.
If you agree with all your statements, select the Send button to submit this
Request for Reconsideration to Social Security.
If you disagree with any of your statements, select the Previous Page
button to go back and correct the information.
Claimant’s name is [Claimant Name]. The Claimant’s mailing address is
[Mailing Address]. The Claimant’s phone number is [nnn-nnn-nnnn].
[Wage Earner’s or Self-Employed Person’s name, if different from the
Claimant, is [Wage Earner Name].[
Claimant’s Social Security Number is xxx-xx-1234. [Claimant’s Claim
Number(s) is/are nnn-nn-nnnn A. The Supplemental Security Income (SSI)
Claim Number is nnn-nn-nnnn A.]
I disagree with the determination made on my claim and request
reconsideration. My reasons are: [data entered].
[{I do not have a representative.
I understand that I have a right to be represented. If I am not represented but
would like to be, the Social Security office can give me a list of legal referral
and service organizations.}
or

{I am represented by [name], who [is/is not] an attorney. The Representative’s
address is [RAddress]. The Representative’s phone number is [nnn-nnnnnnn] [and fax number is [nnn-nnn-nnnn]].
If I am represented and have not done so previously, I will complete and
submit form SSA-1696 (Appointment of Representative).}]
If you have reviewed all of your information and are ready to submit your
Request For Reconsideration, read the statement below. Checking the box
next to your name means that you agree with the statement.
I, [filer’s name], declare under penalty of perjury that I have examined all
the information on this form, and on any accompanying statements or
forms, and it is true and correct to the best of my knowledge.
Important: After you submit this Request for Reconsideration, you
will not be able to come back to it. Check the box next to your
name to indicate you have read the statement and it is accurate.
I, [filer’s name], read and agree with the above.
Previous Page

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iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

26

Receipt of Request For Reconsideration
(Filed By Claimant)

We recommend that you print or save this page for your records now
because you will not be able to return to this page later. We have included
the details of the Request for Reconsideration that we received. If you disagree
with any of your statements, you should contact us within 10 days after [today’s
date] to let us know.
Next Steps
Carefully review the information below. Contact Social Security within ten
days if it is not correct.
Print and keep this confirmation page for your records. (Select this link to
print this page or save it to your computer. For instructions on how to print,
save, or view the saved file, please refer to the Print/Save/View Guide.)
Select the Start Part 2 button at the bottom of this page to begin Part 2 of the
Internet Appeal process, the Disability Report. We will not have all of the
information that we need to process your appeal until you submit the
Disability Report.

The Request for Reconsideration was
received by Social Security on [date] at [time].

Claimant’s name is [Claimant Name]. The Claimant’s mailing address is [Mailing
Address]. The Claimant’s phone number is [nnn-nnn-nnnn].
[Wage Earner’s or Self-Employed Person’s name, if different from the Claimant,
is [Wage Earner Name].]
Claimant’s Social Security Number is xxx-xx-1234. [Claimant’s Claim Number(s)
is/are xxx-xx-5678 A. The Supplemental Security Income (SSI) Claim Number is
xxx-xx-5678 A.]
I disagree with the determination made on my claim and request reconsideration.
My reasons are: [data entered].
[{I do not have a representative.
I understand that I have a right to be represented. If I am not represented but
would like to be, the Social Security office can give me a list of legal referral and
service organizations.}
or

{I am represented by [name], who [is/is not] an attorney. The Representative’s
address is [RAddress]. The Representative’s phone number is [nnn-nnn-nnnn]
[and fax number is [nnn-nnn-nnnn]].
If I am represented and have not done so previously, I will complete and submit
form SSA-1696 (Appointment of Representative).}]
Start Part 2

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iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

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Submit Request For Reconsideration
(Filed By Representative)
Please review the Request for Reconsideration information below before
sending it to the Social Security Administration.
If you agree with all your statements, select the Send button to submit this
Request for Reconsideration to Social Security.
If you disagree with any of your statements, select the Previous Page button
to go back to the questions and correct the information.
Claimant’s name is [Claimant Name]. The Claimant’s mailing address is [Mailing
Address]. The Claimant’s phone number is [nnn-nnn-nnnn].
[Wage Earner’s or Self-Employed Person’s name, if different from the Claimant,
is [Wage Earner Name].]
Claimant’s Social Security Number is xxx-xx-1234. [Claimant’s Claim Number(s)
is/are nnn-nn-nnnn A. The Supplemental Security Income (SSI) Claim Number
is nnn-nn-nnnn A.]
The Claimant disagrees with the determination made on his or her claim and
requests reconsideration. The reasons are: [data entered].
The Claimant is represented by [name], who [is/is not] an attorney. If not done
so previously, the Claimant will complete and submit form SSA-1696
(Appointment of Representative). The Representative’s address is [Raddress].
The Representative’s phone number is [nnn-nnn-nnnn] [and fax number is [nnnnnn-nnnn]].
If you have reviewed all of your information and are ready to submit your
Request For Reconsideration, read the statement below. Checking the box next
to your name means that you agree with the statement.
I, [filer’s name], declare under penalty of perjury that I have examined all
the information on this form, and on any accompanying statements or
forms, and it is true and correct to the best of my knowledge.
Important: After you submit this Request for Reconsideration, you will
not be able to come back to it. Check the box next to your name to
indicate that you have read the statement and it is accurate.
I, [filer’s name], read and agree with the above.
Previous Page

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Send

iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

28

Receipt of Request For Reconsideration
(Filed By Representative)

We recommend that you print or save this page for your records now
because you will not be able to return to this page later. We have included
the details of the Request for Reconsideration that we received. If you disagree
with any of your statements, you should contact us within 10 days after [today’s
date] to let us know.
Next Steps
Carefully review the information below. Contact Social Security within ten
days if it is not correct.
Print and keep this confirmation page for your records. (Select this link to
print this page or save it to your computer. For instructions on how to print,
save, or view the saved file, please refer to the Print/Save/View Guide.)
Select the Start Part 2 button at the bottom of this page to begin Part 2 of the
Internet Appeal process, the Disability Report. We will not have all of the
information that we need to process your appeal until you submit the
Disability Report.

The Request for Reconsideration was
received by Social Security on [date] at [time].

Claimant’s name is [Claimant Name]. The Claimant’s mailing address is [Mailing
Address]. The Claimant’s phone number is [nnn-nnn-nnnn].
[Wage Earner’s or Self-Employed Person’s name, if different from the Claimant,
is [Wage Earner Name].]
Claimant’s Social Security Number is xxx-xx-1234. [Claimant’s Claim Number(s)
is/are xxx-xx-5678 A. The Supplemental Security Income (SSI) Claim Number is
xxx-xx-5678 A.]
The Claimant disagrees with the determination made on his or her claim and
requests reconsideration. The reasons are: [data entered].
The Claimant is represented by [name], who [is/is not] an attorney. If not done so
previously, the Claimant will complete and submit form SSA-1696 (Appointment
of Representative). The Representative’s address is [Raddress]. The
Representative’s phone number is [nnn-nnn-nnnn] [and fax number is [nnn-nnnnnnn].]
Start Part 2

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iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

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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)

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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)

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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

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iAppeals Screens for the final PSA (May 24)

Name: John Public
SSN: xxx-xx-1234

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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

Continue

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

Continue

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

Last edited 4/13/2007 4:46 PM

Continue

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.
Last edited 4/6/2007 6:11 PM

32

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.
Last edited 4/6/2007 6:11 PM

33

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

34

iAppeals Screens for the final PSA (May 24)

36

iAppeals Screens for the final PSA (May 24)

37

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.
Last edited 5/16/2007 9:31 AM

38

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.
Last edited 5/16/2007 9:31 AM

39

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