SSI Facilitation- Forms

Revised on August 23, 2016

Purpose

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.

Name

Number

Purpose

Application for Disability Insurance Benefits

Internet iClaim or SSA-16-BK

Apply for Social Security Disability (Title 2 application).

Application for Supplemental Security Income

SSA-8001-F5

Apply for SSI (Title 16 application).

Authorization to Disclose Information to the Social Security Administration

SSA-827

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

SSA-3288

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

Disability Report- Adult

i3368 or

SSA-3368-BK

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).

SSI Cover Letter

DSHS 02-577

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

SSI Legal Representation

DSHS 09-792

Client notice. Resource list of legal representatives.

 

Links

Electronic DSHS Forms

Social Security Administration Forms