Disability Report - Appeal
5. Since you last told us about your other medical information, does anyone else have medical information
about any of your physical or mental conditions (including emotional and learning problems) or are you
scheduled to see anyone else?
This may include:
•
workers’ compensation
•
vocational rehabilitation services
•
insurance companies who have paid you disability benefits
•
prisons and correctional facilities
•
attorneys
•
social service agencies
•
welfare agencies
•
school/education records
□ Yes (Please complete the information below.)
□ No (Go to SECTION 6 – MEDICINES)
Name of Organization Claim or ID Number (if any)
Address
City State/Province ZIP/Postal Code Country (if not U.S.)
Name of Contact Person Phone Number
Date of First Contact Date of Last Contact Date of Next Contact (if any)
SECTION 5 – OTHER MEDICAL INFORMATION
NAME OF MEDICINE
IF PRESCRIBED,
NAME OF DOCTOR
REASON FOR MEDICINE
SIDE EFFECTS
YOU HAVE
No (Go to SECTION 7 – ACTIVITIES)
□
□
Yes (Please complete the information below. You may need to look at your medicine containers.)
6. Are you currently taking any medicines (prescription or non-prescription)?
Reasons for Contacts
If you need to list more people or organizations, use SECTION 10 – REMARKS on the last page.
SECTION 6 – MEDICINES
If you need to list more medicines, use SECTION 10 – REMARKS on the last page.
Form SSA-3441-BK (03-2015) ef (03-2015)
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