DISABILITY REPORT - APPEAL
PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT
This report is used to update your information for your disability appeal. Completing this report accurately
helps us process your claim. Please complete as much of this report as you can.
IF YOU NEED HELP
Please do not ask your health care provider to complete this report. You can get help from other people,
such as a friend or family member. If you cannot complete this report, a Social Security representative
can assist you. If you make an appointment with us, please complete as much of this report as you can
and have it with you for your appointment.
HOW TO COMPLETE THIS REPORT
If you have Internet access, you may be able to complete this report online at
If you complete this report on paper:
Print or write clearly.
Include a ZIP or postal code with each address.
Provide complete phone numbers, including area code. If a phone number is outside the
United States, also provide International Direct Dialing (IDD) code and country code.
If you cannot remember the names and addresses of your health care providers, you may be
able to get that information from the telephone book, Internet, medical bills, prescriptions, or
prescription medicine containers.
ANSWER EVERY QUESTION, unless this report indicates otherwise. You can write "don't
know," or "none," or "does not apply" if you need to.
If you need more space to answer any question, please use the REMARKS section on the last
page, SECTION 10. Include the number of the question you are answering.
YOUR MEDICAL RECORDS
If you have any medical records that you have not given to us, send or bring them to our office with this
completed report. Please tell us if you want us to return them to you. If you are having an interview in our
office, bring your medical records, your prescription medicine containers (if available), and this completed
report with you.
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS THAT YOU
DO NOT ALREADY HAVE. With your permission, we will request your records. The information that you
give us on this report tells us where to request your medical and other records.
HOW TO SUBMIT THIS REPORT
Send or bring this completed report to your local Social Security office. If you have Internet access, you
can locate your nearest Social Security office by zip code at www.socialsecurity.gov/locator. Our offices
are also listed under U.S. Government agencies in your telephone directory or you may call Social
Security at 1-800-772-1213 (TTY 1-800-325-0778).