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Form SSA-454-BK - How to Complete

Tips For Completing Form SSA-454-BK

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Section 1. Information About The Disabled Person

 The purpose of this section is to provide enough information so that an examiner can identify your medical and work records.

  • 1.D. The purpose of asking for a daytime telephone number is so that an examiner can contact you if needed to clear up something that is confusing or for additional information. If you do not have a phone, please provide a name and phone number of someone who can get in touch with you quickly. (It is advisable to let that person know that he or she may be called with a message for you.)
  • 1.F. If you cannot speak or understand English:
    • Social Security will provide an interpreter, free of charge, when you talk with the agency about your claim.
    • Social Security has booklets and letters written in languages other than English that may help.
    • Social Security takes this into account when deciding whether you can do other types of work. If you cannot speak, read or write English, it may be more difficult to do some jobs.
  • 1.G. Please be sure to include all names you have used, including maiden name, to help avoid examiner confusion - and delay in processing your claim.

Section 2. Contacts

This section asks for a contact person other than yourself. This should be someone who is aware of your condition and how it it has affected you when you worked if you are no longer working or your ongoing ability to work if you are still working. It would also be helpful if that person knows about the problems you are experiencing outside of work because of your health condition(s).  Examples of people who are listed most often: a relative, friend, and co-worker. (Do not list your medical doctor.)

The person you name should be informed that you are receiving an income from Social Security Disability and that you are listing his/her name. There is a form called Daily Activities Questionnaire, Third Party that this person may be asked to complete. It would be helpful if that person reviewed the form before you submit the SSA 3368-BK form so you are both in sync.  

It can save time to get a statement from that person to give to Social Security when you go for your interview. See Affidavits From Friends, Family and Co-Workers.

Do not list your current doctor in this section.

  • 2.A  IF you want to include additional people because they know your condition and how it affects your ability to work, feel free to include them in Section 11 or an extra page.
  • 2.F. Note that if someone other than you or the contact person listed above completes the SSA 3368-BK for you, that person should complete the rest of Section 2.

Section 3. Medical Condition(s)

Social Security considers all your illnesses, injuries and conditions when deciding if you are disabled.  It does not matter whether or not you received treatment for them.

  • 3.A 
    • List all of your health conditions by diagnosis, all injuries, and all conditions and symptoms. 
      • Be sure to include all conditions listed when you first applied for SSDI on form SSA 3368-BK and any other condition which you have told Social Security about since the application.
      • Do not try to judge what does and does not affect your work. Include old ailments that may still affect you, such as a bad back. Include symptoms or impairments that you may consider to be embarrassing. For example, some people don't list an inability to control bowels or urine, yet those very symptoms could be very important to help explain why you can't work.
    • While any single condition may not be disabling, the combination of conditions can qualify you for SSDI benefits by limiting your ability to work. 
    • The health conditions do not have to be work related conditions.
    • Keep in mind that these illnesses may be mental/emotional as well as physical, including the nervous system. If you have not already considered it, think about whether you are experiencing anxiety and/or depression. Anxiety and depression are likely to accompany not being able to work because of a health condition. Even if the condition on its own is not enough to obtain a disability determination, it may be a contributing factor that together with your physical health condition(s) allows you to be considered to be "disabled" for SSDI purposes.
    • Include health conditions for which you have not seen a medical professional. NOTE: If mental or nervous symptoms are included as reasons you cannot work, a therapist or other practitioner who is treating you should be listed in Section 4. Social Security tends not to give much credence to untreated depression and other mental symptoms.
    • Do not exclude current health conditions because they do not seem relevant to your ability to work. 
    • Side effects of medications should be treated as symptoms and listed if they are a factor limiting your ability to work.
    • Use your own words if you do not know the medical name.
    • If you need more room to write, use Section 11 or add an extra page.
    • NOTE: 
      • Alcohol and drug abuse are not symptoms and cannot be used to determine if you are disabled for Social Security purposes. However, any physical or mental problems you suffer as the result of past abuse can be usable symptoms. For example, current addiction to cocaine will not be considered in determining whether you are disabled. However, cirrhosis of the liver due to past alcoholism will be considered.
      • If you are not keeping a health journal, consider starting one. In addition to being helpful with Social Security, it is likely to improve your relationship with your health care provider.
  • 3.B, 3.C  If you do not know your height and/or weight, you can say "about". For instance: "about 150 pounds" or "about 5'6"

Section 4 - Work

  • As with all other questions, answer this question honestly. 

Section 5 - Medical Treatment

Social Security wants the name and complete mailing address of all your treating doctors, medical practitioners, clinics and hospitals.

  • Keep in mind that it is the records from these sources that Social Security will use to decide whether or not you continue to be disabled so it is in your best interest to give a complete list. 
  • Make sure you give complete and accurate information including name, mailing address, ZIP code and telephone numbers.  
  • Social Security does not ask your doctors to decide if you are disabled. That will be determined by Social Security under its rules.

Start with the doctor who has the most current and complete records of your condition. If you are treated at a clinic or medical group by several doctors but all use the same medical record file, then you need only list the group but be sure to list all the doctors that you have seen.

List all other doctors who are treating you including specialists, therapists, physical therapists, acupuncturists, chiropractors, and other practitioners. Some of the records from alternative medical practitioners wouldn't be enough to prove a disability claim, but they can support the other records.

Include physicians you used to see but are no longer seeing as long as their records have information relating to any of the conditions that are causing your inability to work or contribute to that inability.

TIP: If some of your records were at a physician who is no longer in practice, consider trying to obtain those records yourself because Social Security is not likely to try all that hard. Possibly the practice was sold and you will be able to find the records with the new owner of the practice, or you may end up finding the doctor and pulling the records out of her garage.

  • To get a mailing address, you can check online, your appointment card, your billing statement or call the doctor's office.
  • If a doctor has more than one office, provide the address for the location where you are or were treated or where your medical records are kept.
  • If you cannot remember exact dates, provide approximate dates.  For example, you can write "about 2 years ago", "last year" or "6 months ago." 
  • Provide information at least since you became unable to work, and preferably before then. In addition to deciding whether you are disabled under the rules now, there must also be a decision about when you first became disabled.
  • Consider contacting your doctors' office for the information and/or dates regarding your treatment.
  • Include every treatment you have undergone whether it relates directly to your disability or not.  Although all of the tests should be evidenced in the medical record, some may be buried or overlooked by Social Security personnel, so it is important that you be thorough and list them here. Use Section 11 -- Remarks for tests that aren't listed on this form.
  • Note that Social Security is interested in tests that are planned for you in the future as well as tests that have been completed.
  • Social Security looks to some tests to confirm the presence of a medical problem. Other kinds of tests may indicate the extent of physical limitations caused by an illness, injury or condition. For example, a breathing test can show limitations caused by a lung condition.
  • If you had, or are going to have a test performed that is not listed in this section, provide the information in Section 11 - Remarks. Include the contact information of the doctor who sent you for testing.
  • A quick summary of the tests:
    • EKG (Heart test): The patient sits, stands or lies down while wires are placed on the skin. A machine attached to the other ends of the wires prints out wavy lines on a chart that shows the electrical activity of the heart.
    • Treadmill (Exercise test): The most common of these tests conducted while the patient exercises involves a treadmill. An EKG records the patient as he or she walks on a treadmill.
    • Cardiac Catherization: A heart test in which the doctor passes a thin wire into the heart through an artery - usually through a groin area.
    • Biopsy: The doctor removes tissue from a part of the body to see if disease is present. (Include the name of the body part biopsied)
    • Hearing test: A specialist plays different tones through earphones to test hearing loss
    • Speech-Language test: Used to evaluate your ability to use speech and language to communicate with others.
    • Vision test: an eye test to check your vision - usually by reading letters from a chart.
    • IQ test: A series of short tasks that require either a written or spoken response to help measure your understanding of information and ability to solve problems.
    • EEG: (Brain Wave Test) - Wires placed on the scalp lead to a machine that measures and records brain wave activity.
    • HIV test: Tests blood for the presence of the human immunodeficiency virus (HIV)
    • Blood test: Tests blood for abnormalities in a laboratory
    • Breathing test: The patient exhales into a machine that measures breathing capacity of the lungs
    • X-ray  A machine which takes pictures of body parts.  Include the name of the body part x-rayed. For more information, see X-ray.
    • MRI/CT scan: different methods of imaging body parts.  For more information, see: MRICT Scan
  • NOTE: 
    • If you already have copies of your medical records in your possession from your doctors, hospitals, clinics and other medical sources, it will help speed processing of your claim because they will not have to be requested.  If you do not have the records, it can help to let the health care provider(s) know the request will be coming in order to speed the process when the request is received.
    • If you have not received treatment, or Social Security does not get enough informatoin about your illnesses, injuries or conditions, it may ask you to have a special examination and/or test.

Section 6 - Other Medical Information

The form asks about other places that may have medical information about you including such places as workers compensation, vocational rehabilitationinsurance companies that have paid disability compensation, prisons, attorneys, social service agencies and welfare.

If there is someone who is aware of your condition and knows that you are receiving benefits from Social Security Disability - consider adding that person's name and contact information in Section 11 - Remarks. There is a form called Daily Activities Questionnaire, Third Party that the person may be asked to complete so make sure it is someone who knows the problems you had when you worked. It would also be helpful if that person knows about the problems you are experiencing now because of your health condition(s). Let that person know you are giving his or her name to Social Security. It would be helpful to get a statement from that person to give to Social Security if you are interviewed. See Affidavits From Friends, Family and Co-Workers.

Section 7 --  Medicines

  • List all your medications you take on a regular basis. In addition to prescription medications, include over-the-counter medications such as aspirin and laxatives. Also include any complementary medications, herbs such as St. John's Wort and home remedies, 
  • Include medicines even if they are not for the current illnesses, injuries or conditions for which you are filing a disability claim.
  • For prescription medicines, you can get the name from the container. If you do not have the container, you can provide the common name or the type of medicine (such as heart medicine or arthritis medicine.  
  • Include dosage and frequency.
  • The prescribing doctor does not have to be your current doctor. If you cannot remember the doctor's name, write "unknown" in the space.
  • If the medicine was not prescribed by a doctor, you can write "over the counter" or the type of medication it may be such as "herbal" or 'home remedy"
  • "Reason for medicine" is why you are taking the medicine. Examples include "to slow down my heart rate," "for high blood pressure," "to help me sleep at night," "for pain relief. "  The reason is important because some medicines can be prescribed for different reasons.

Section 8 -- Education and Training

This section gives Social Security an idea of other types of work for which you may be suited. Note that this section focuses on formal training. Keep in mind that to qualify for "Disability" within Social Security's definition, you must not only be unable to do the work you used to do, but any work for which you are qualified.

If your health condition affected your ability to attend school or job training, note it in Section 11 - Remarks.

Section 9 - Vocational Rehabilitation, Employment Or Other Support Services

For information about the following programs, click on the link:

Section 10 - Daily Activities

Before answering this section, review your previous Daily Activities Worksheet if you used one when applying for SSDI or for another disability review.. It will help if you are asked about changes between then and now.

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