SSI Facilitation- Forms

Revised on March 9, 2020


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

NOTE: Use the Internet version of forms whenever available.




Application for Disability Insurance Benefits

Internet iClaim or SSA-16-BK

Apply for Social Security Disability (Title 2 application).

Application for Supplemental Security Income


Apply for SSI (Title 16 application). SSI Facilitators use a simplified paper form (SSA-8001) in agreement with SSA.

Authorization to Disclose Information to the Social Security Administration


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

Consent for Release of Information


Receive copies of Consultative Exams, disability determination letters, etc.

Disability Report- Adult

i3368 or


Report client’s medical conditions, employment history, education, and medical treatment. (The i3368 is connected to the Internet iClaim).
Disability Report- Appeal iAppeal or SSA-3441-BK Report used to update client information (medical conditions and medical treatment) for a disability appeal.
Function Report- Adult SSA-3373-BK Report how client’s condition(s) limit their daily activities.

Interim Assistance Reimbursement Authorization

DSHS 18-235

Repayment agreement when state benefits are duplicated by federal benefits.

Request for Hearing by Administrative Law Judge HA-501-U5 Request an appeal hearing when a reconsideration has been denied. (This form is included in the iAppeal).
Request for Reconsideration SSA-561-U2 Request a reconsideration when denied at the initial determination. (This form is included in the iAppeal).
Request for Review of Hearing Decision/Order HA-520-U5 Request for Appeals Council to review an Administrative Law Judge’s decision.

SSI Cover Letter

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

Cover letter for initial application, reconsideration, or hearing packet.

SSI Legal Representation

DSHS 09-792

Client notice. Resource list of legal representatives.

Statement of Claimant or Other Person SSA-795 All purpose form. This may be used to provide SSA with a signed statement regarding a SSI/SSDI claim (e.g. Good Cause Statement).
Work History Report SSA-3369-BK Report client’s vocational information for jobs 15 years prior to becoming unable to maintain substantial gainful activity due to health conditions.