Disability Report - Appeal

Form SSA-3441-BK (03-2015) ef (03-2015)
Page 3
SECTION 4 – MEDICAL TREATMENT (continued)
Provider 1
go to SECTION 5 – OTHER MEDICAL INFORMATION on page 6.
If you do not have any more providers to describe,
If you need to list more tests, use SECTION 10 - REMARKS on the last page.
4. D. Name of facility or office
Name of health care provider who treated you
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone Number
Patient ID# (if known)
Address
First Visit _________________
Last Visit _________________
Next scheduled appointment
(if any) ___________________
Emergency Room visits at
this facility
Office, Clinic or Outpatient visits at
this facility
Date __________________
Date __________________
Date __________________
o None
Overnight hospital stays at
this facility
Date in _____ Date out _____
Date in _____ Date out _____
Date in _____ Date out _____
o None
What medical conditions were treated or evaluated?
What treatment did you receive for the above conditions? (Do not list medicines or tests in this box.)
City
State/Province ZIP/Postal Code
Country (if not U.S.)
Dates of Treatment (approximate date, if exact date is unknown)
Biopsy (list body part)
X-ray (list body part)
MRI/CT Scan (list body part)
___________________
EKG (heart test)
Other (please describe)
__________________
Hearing Test
DATES OF
TESTS
Has this provider performed or sent you to any tests? Please include tests you are scheduled to have in the
future.
No (Go to the next page.) Yes (Please complete the information below.)
Vision Test
Speech/Language Test
Breathing Test
EEG (brain wave test)
IQ Testing
HIV Test
Cardiac Catheterization
Blood Test (not HIV)
__________________
KIND OF TEST
DATES OF
TESTS
Treadmill (exercise test)
__________________
KIND OF TEST
Page 5/10
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