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SSI Forms


Revised December 13, 2011



Purpose: This section includes a list of common forms you may use or encounter in SSI Facilitation.

Use the Internet version of forms where available.

Name

Number

Description

Aging and Adult Services Comprehensive Assessment

DSHS 14-327

Assessment, documenting disabilities.

Application for Disability Insurance Benefits

SSA-16-F6

Apply for Social Security Disability.

Application for Supplemental Security Income

SSA-8001-F5

Apply for SSI.

Authorization for Source to Release Information

SSA-827

SSA uses this form to obtain medical records. (If disabled child is age 12 or over, child must sign the 827).

Five-day Hospice Notice

DSHS 13-746

Documentation of terminal illness.

Interim Assistance Reimbursement Authorization

DSHS 18-235

Repayment agreement when state benefits are duplicated by federal benefits.

Internet Adult Disability and Work History Report

I3368PRO

Replaces the SSA 3368 and SSA 3369. Education, employment, and medical information for SSA.

Medical History and Disability Report-Child

SSA-3820-F6 or i3820

Recording disability information for a child.

Reconsideration Disability Report

SSA-3441-F6 or i3441

Information when filing a request for reconsideration or hearing .

Referral for SSI

DSHS 11-017

Cover letter for application packet.

Request for Approval from State Office for Expenditure

DSHS 17-118

Obtain authorization to pay more than the maximum for SSI records.

Request for Hearing by Administrative Law Judge

HA-501-U5

Request an appeal hearing when a reconsideration is filed.

Request for Reconsideration

SSA-561-U2

Request a reconsideration.

SSI Legal Representation

DSHS 09-792

Client notice.

SSI Rights and Responsibilities

DSHS 14-411

Information for client.

Modification Date: December 13, 2011