The form is used whenever section 3, information about your work on the ssa 3368 bk shows more than one job in the last 15 years, even if all the jobs have been listed on the ssa 3368. Create form ssa 3368 bk in minutes using a fillable pdf editor. This disability report form is the launching point from which your entire medical eligibility decision will evolve. Disability report adult social security administration. Ssa form 3368, the adult disability report, is the most comprehensive and, some argue, the most important of the forms that you will fill out when applying for disability benefits from the social security administration. Publications may also be downloaded for free from our website at. Filing a disability application with social security ssdi. How to fill out form ssa3368 disability benefits help. Bear in mind that filling out form ssa3368 is only the first step in claiming disability benefits. Security benefit statement form ssa1099 showing the amount of benefits you disability report adult social security form ssa3368bk 122012 ef 122012 use 012010 edition until exhausted. If you have not had a career change or job type change in the past fifteen years, you. Ssa automated the ssa 3368 bk, the internet adult disability report i3368, in 2002. Ssa 3368bk is the basic form which must be completed by every adult who applies for any social security disability insurance benefits, including ssdi, ssi, disabled spouse, exspouse or widower benefits and disability benefits claims. Description of ssa 821 bk 04 2012 form 2011 ssa 3369 form.
The ssa has other forms which they will ask your doctor to fill out on your behalf. The information you give us on this report will be used by the office that makes the disability decision on your disability claim. Adult disability report helps dds to obtain a complete picture of the applicants medical history and treatment. Psc publishing services disability report adult social security. Page 1 disabilit y reporta dultform ss a3368bk form ssa3368bk 32008 ef 032008 use 62003 and later editions until supply is exhausted yes no your number message number none area. Fill ssa form 821 20122017 ssa instantly, download blank or editable online. Form ssa3368bk 012010 ef 042010 what we mean by disability disability under social security is based on your inability to work.
It is a very lengthy form that can be filled out either on paper or online. Ssa 3368 fillable form pdf form ssa3368bk 112014 ef 112014. The adult disability report provides information about the applicant and should be completed online after completing the online. Ssa1bk, application for retirement insurance benefits. Fillable form ssa3369bk free printable pdf sample formswift. Call us at 180077212 if you cannot provide these documents. Summary plan description 2011 central pension fund. Form ssa3368bk 102015 uf 102015 what we mean by disability disability under social security is based on your inability to work. Sign, fax and printable from pc, ipad, tablet or mobile. Work history report form ssa3369bk rea d all of this information before. Medical history printable form health medicare pdfs. If you need help with this form, do as much of it as you can, and your. Form ssa827bk, authorization to disclose information to the social security administration. Ssa3441, disability report appeal social security disability report appeal form ssa3441bk.
The information that you give us on this report tells us where to request your medical and other records. Form ssa 3368 bk 122012 122012 7 of 14 page 5 32420 2. Overnight hospital stays list the most recent date first 2. The disability reportadult form ssa3368bk is required to file a claim. A form ssa 3368bk is known as an adult disability report. The previous editions of this document are obsolete.
Fill disability report adultform ssa3368bk social security ssa instantly, download blank or editable online. Form ssa455 download printable pdf or fill online disability. You can fill the form out yourself or have a representative such as a social security disability lawyer help you with it, but you should not have your doctor fill out any of it. Completing this report accurately and completely will help us expedite your. Form ssa3368bk, adult disability report, form ssa3369bk, work history report, and. Social security administration form approved omb no. You may fill it out yourself or, if it makes you feel more comfortable, you may have a social security disability attorney or advocate help you fill it out. It is also used for adults who are age 18 or over who became disabled prior to age 22.
Read all please use section 10 remarks on page 7, and show the number of the question being. Retirement survivors disability supplemental security income. Ssa 3368 is the basic form all social security disability claimants must fill out to apply for social security disability benefits. The form ssa 3369bk is known as the work history report, and it will need to be included will any application for benefits, such as disability or ssi benefits. The form is used whenever section 3, information about your work on the ssa3368bk shows more than one job in the last 15 years, even if all the jobs have been listed on the ssa3368. When the case manager is ready to submit the complete application packet, heshe can transfer information from the paper ssa3368 to the online version. Disability report adult form ssa3368bk please read all of this information before you begin completing this form this is not an application. Ssa2bk 072018 uf b check one box and provide the date in c a have you or has someone on your behalf ever filed an application for social security benefits, a period of disability under social security, supplemental security income, or hospital or medical insurance under medicare. Form ssa 16 bk, application for disability insurance benefits.
You will find job history information on form ssa 3368 bk, section 6 you will find a list of jobs with basic information in section 6. The information you give us on this report will be used by the. The instructions, gather the facts, and answer the questions. Ask va to help you fill out the form by calling us at 1877222vets 8387. Social security administration staff or others who help people apply for ssi will fill out this form for you.
The following lists are examples of the types of documents you must provide with your application and are not all inclusive. Disability report adult form ssa3368bk please read all of this information before you begin completing this form this is not an application if you need help if you need help with this form, do as much of it as you can, and your interviewer will help you finish it. Ssa3368 is the basic form all social security disability claimants must fill out to apply for social security disability benefits. Please call us at 180077212 tty 18003250778 monday through friday between 8 a. Access vas to determine your eligibility for medical benefits and on average will take 30 minutes to complete. It lists the applicants conditions, education, work history, treating sources, and other information that informs dds about his or her disability. Work history report form ssa 3369 bk read all of this information before you begin completing this form if you need help if you need help with this form, complete as much of it as you can. The form you are looking for is not available online. Work history report form ssa3369bk form ssa3369bk 042011 ef 042011 destroy prior editions social security administration work history report form approved omb no. By clicking submit, i hereby consent to receive autodialed andor prerecorded phone calls from a disability advocate or attorney at the telephone numbers provided above, even if that phone number is a wireless number and even if you have previously registered that phone number on a do not call list. Form ssa16 062018 uf discontinue prior editions social security administration. Form ssa3368bk 122012 122012 7 of 14 page 5 32420 2. I apply for a period of disability andor all insurance benefits for which i am eligible under title ii and part a of title xviii of the social security act, as presently amended.
Fill out, securely sign, print or email your ssa 3368 20152020 form instantly with signnow. Social security administration on october 1, 2011 and used countrywide. How to fill out form ssa 3368 form ssa 3368 is the basic form used for adults who are claiming disability benefits. Free medical history form printable medicare gcode. Adults use ssa 3368 bk 1298 which can be obtained by clicking on. How to fill out form ssa3368 disability benefits center. Work history report social security administration. This includes the time it the paperwork reduction act of 1995 requires us to notify you that this information collection is in accordance. Be sure to include all information available to you. This form will be used by the united states social security administration.
Ss5 112019 uf discontinue prior editions page 1 of 5. Disability report adult ssa 3368 bk please read this information before completing this report the information you give us on this report will be used by the office that makes the. Send only comments relating to our time estimate to this address, not the completed form. Many forms must be completed only by a social security representative. The information you give us on this report will be used by the office that makes the disability. Ssa automated the ssa3368bk, the internet adult disability report i3368, in 2002. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. You will find job history information on form ssa3368bk, section 6 you will find a list of jobs with basic information in section 6. How to fill out form ssa3368 social security disability help. The form ssa 3369 bk is known as the work history report, and it will need to be included will any application for benefits, such as disability or ssi benefits. Form ssa3369bk, work history report is a form used for providing the social security administration ssa with detailed information about all jobs you performed in the past 15 years. You may need to develop additional job history, particularly when the information is.
A form ssa 3368 bk is known as an adult disability report. Form ssa 3380 bk 12 2009 fill out and sign printable pdf. If you decide to file online, you may need some guidance filling in. Organizing ssdi claims for paralegals ondemand audio. This form is a major part of any application for social security disability or ssi benefits. Disability report adultform ssa3368bk you can get help from. Disability report adult ssa3368bk please read this information before completing this report the information you give us on this report will be used by the office that makes the. Form ssa16bk, application for disability insurance benefits. Form ssa3368 is the basic form used for adults who are claiming disability benefits. Disability report adultform ssa3368bk ssa827 social security. For purposes of this claim, we want you to understand that disability means you are unable to work as defined by the social security act. If you need help with this form, do as much of it as you can, and your interviewer will help you finish it. Then call the phone number provided on the letter sent with the form or the phone number of the person who asked you to complete the form for help to finish it. Dec 20, 2019 disability report adultform ssa3368bk ssa827 social security.
Application for supplemental security income ssi deferred or abbreviated. Form ssa3368bk 112014 ef 112014 disability report adult ssa3368bk please read this information before completing this report. Adult disability report social security disability. Social security forms social security administration. The form ssa 3369 bk is to be completed to document your work history. However, if you have access to the internet, you may access the disability. Form ssa3368bk 112014 ef 112014 what we mean by disability disability under social security is based on your inability to work. Upon submitting this form, you will receive an email andor a phone call shortly during regular business hours. If you have not had a career change or job type change in the past fifteen years, you probably do not need this form. Form ssa3368bk 012010 ef 042010 destroy prior editions. The latest version of the form also known as the ssa form 3369bk was released by the ssa in april 2014.
Adults use ssa3368bk 1298 which can be obtained by clicking on. The form ssa3369bk is to be completed to document your work history. If you download, print and complete a paper form, please mail or take it to your local social security office or the office that requested it from. Comments and help with ssa 3369 bk fillable no no download needed needed. List all the jobs that you had in the 15 years before you became unable to work because of your illnesses, injuries or conditions. Work history report form ssa3369bk read all of this information before you begin completing this form if you need help if you need help with this form, complete as much of it as you can. Adult disability report social security disability definition. Form ssa 3368 bk type of business utili dates worked from 91986 102010 hours day 8 days. Ssa 3368 bk is the basic form which must be completed by every adult who applies for any social security disability insurance benefits, including ssdi, ssi, disabled spouse, exspouse or widower benefits and disability benefits claims.
Work history report form ssa 3369 bk form ssa 3369 bk 04 2011 ef 04 2011 destroy prior editions social security administration work history report form approved omb no. Application for supplemental security income ssi form approved omb no. The disability reportadult form ssa 3368 bk is required to file a claim. Form ssa 827 bk, authorization to disclose information to the social security administration.
Medical treatment continued tea us may have medical records about any of your physical andor mental conditions including. A disability advocate will give you a free evaluation of your disability claim. This form will need to include all the information about your previous employment in order to determine your eligibility for benefits. Social security disability benefits state council on developmental. Free blank medication administration form medicare gcode. Form ssa 3368 bk 012010 ef 042010 destroy prior editions. Form ssa 11 bk 012014 ef 012014 use 082009 ef 082009 edition until exhausted social security administration request to be selected as payee form approved omb no.
Disability report adultform ssa3368bk va form 1010ez veterans affairs. Ssa 3368 form online printable fill out and sign printable pdf. If the claimant had only one job in the last 15 years, then you may find a complete vocational description of that job in sections 6. Form ssa3373bk form ssa3368bk disability report adult ssa3441 disability report appeal credit accreditation details. Fillable form ssa3368bk free printable pdf sample formswift. Start a free trial now to save yourself time and money. The omb approval number for the internet adult disability and work history report is 09600579. Form ssa3368bk is a disability report for adults that is used by the social security administration. Do not write in this space application for disability. Form ssa 3368 bk, adult disability report, form ssa 3369 bk, work history report, and. The i3368 allows applicants to provide medical and work history information through the internet when filing for disability benefits. Retirement survivors disability supplemental security. Now youll be able to print, download, or share the document.
Form 3368 is an 11section form that you must complete prior to your social security disability interview. Fill social security administration form ssa 3368 secure instantly, download blank or editable online. Form ssa11bk 012014 ef 012014 use 082009 ef 082009 edition until exhausted social security administration request to be selected as payee form approved omb no. As a social security claims rep ive had to fill out that form for hundreds of beneficiaries who were too lazy to fill it out themselves. Fill out, securely sign, print or email your ssa 3380 bk 12 2009 form instantly with signnow. Ssa use only number holder if other than above ssn name form approved whose birthday mmddyy ssn name first middle last records to be disclosed omb no. Form ssa827 112012 ef 112012 use 42009 and later editions until supply is of what all my medical records.
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