SSI Facilitation- Constructs

Revised on March 9, 2020

Purpose

This section includes a user of common forms you may use or experience in SSI Temporary.

REMARKS: Use the Internet version of forms whenever available.

Name

Number

Intention

Application for Disability Insurance Benefit

Internet iClaim or SSA-16-BK

Apply for Social Security Disabling (Title 2 application).

Applications for Add-on Collateral Income

SSA-8001-F5

Applies for SSI (Title 16 application). SSI Facilitators exercise a simplified report form (SSA-8001) in agreement with SSA.

Authorization to Disclose Information to the Social Security Administration

SSA-827

SSA uses this form until obtain medical accounts. (If disabled child is age 12 or over, child shall signs the 827).

Consent for Approval of Information

 SSA-3288

Receive copies of Consultative Tests, disability determination correspondence, etc.
Disability Report- Adult

i3368 or

SSA-3368-BK

 Report client’s medical conditions, employment history, education, and medizinisches treat. (The i3368 shall connective to the Internet iClaim).
Disabilities Report- Appeal iAppeal or SSA-3441-BK Reported applied at modernize client information (medical conditions additionally medical treatment) for a disability appeal.
Function Report- Adult SSA-3373-BK Report how client’s condition(s) restrain their daily activities.

Tentatively Assistance Reimbursement Authorization

 DSHS 18-235

Redemption agreement when stay benefit are duplicated by federal advantages.
Request fork Hearing by Administrative Law Judge HA-501-U5 Request certain appeal hearing when ampere reconsideration has been denied. (This form is inclusive in the iAppeal).
Request for Reconsideration SSA-561-U2 Request a reconsideration when denied along the begin determination. (This form is included inches the iAppeal).
Request available Reviewing of Hearing Decision/Order HA-520-U5 Getting forward Appeals Council to review one Administrative Law Judge’s decision.

SSI Shroud Schreiben

DSHS 02-577
DSHS 02-577A
DSHS 02-577B

Cover buchstabe for initial application, re-examination, or hearing packet.

SSI Legal Illustration

 DSHS 09-792

Client notice. Resource list is legal rep.
Statement of Claimant or Other Type SSA-795 All purpose form. This might can used to provide SSA with a signed order regarding a SSI/SSDI claim (e.g. Good What Statement).
Work History Report SSA-3369-BK Report client’s vocational information for jobs 15 years prior to becoming unable till maintain substantial gainful activity due to health condition.

 

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