FORM SSA 3368 PDF

You can fill the form out yourself or have a representative such as a Social Security Disability lawyer help you with it, but you should not have your doctor fill out any of it. The SSA has other forms which they will ask your doctor to fill out on your behalf. You should include copies of all of your pertinent medical records when you turn this form in. Much of Form SSA is simple and straightforward. You should always answer all questions as completely as you can. Use additional paper if you need to.

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Complete information is essential. Be sure to include all information available to you. If you have all the information, it should only take about 20 minutes to complete. It asks for the same kinds of information as the Online Adult Disability Report. You can use this as a guide to prepare for completing the SSA SSA Section 1: Information about the Disabled Person This section asks for identifying information and contact details for the applicant.

Mailing address: For applicants experiencing homelessness, provide an address where they are comfortable receiving mail. Contact number: For applicants who do not have a phone, they may provide the number of a friend or local shelter where they can be contacted.

It is helpful to document who the phone number belongs to in this question. If the applicant has someone other than the SOAR representative helping them with the application, you can enter multiple contacts in this section. Question 2f asks about who is completing the report. It is important to answer that the SOAR representative is completing the report, so that SSA and DDS know that the applicant needed assistance in gathering details and filling out the form. Applicants may be approved on a combination of physical and mental health conditions, so it is important to be comprehensive in this section.

Note: If you list substance use as a condition that limits his or her ability to work, you need to include substantial evidence that the use is not material to his or her disability. More information about materiality can be found here.

Tip: If the applicant has cancer, include the type and stage, as the applicant may qualify for a Compassionate Allowance. Note that symptoms of mental illness are included in this question. SSA Section 4: Work Activity Questions in this section are broken down into three different parts, depending on it they have never worked, stopped working, or are continuing to work.

Applicants only need to answer one of these sections, depending on their situation. Note that the date provided in this section for when the applicant stopped working, or when their conditions became severe enough to prevent them from working, should match the date provided in the SSA and SSA Otherwise, the claim could experience delays at SSA.

For applicants who stopped working, SSA will ask if they stopped because of their conditions or other reasons. If this applies, SSA will ask the applicant when they believe their conditions became severe enough to prevent them from working. SSA will also ask if the applicant had changes in his or her work activity prior to the date he or she stopped working.

It is important for SSA to know if an applicant needed to change job duties or hours worked based on their conditions.

If the applicant is currently working, provide information about any changes in his or her work activity. For example, an applicant may be able to work 10 hours per week, but his employer allows extra breaks and a flexible schedule when the applicant experiences anxiety. Information about this employer accommodation is not available to SSA in an earnings record, so it is important to provide details on the SSA SSA Section 5: Education and Training Provide information in this section about the highest grade the applicant completed and details about special education or specialized training.

If the applicant is unsure about the dates of school or training, this can be estimated. Information about special education can be valuable to the disability determination. Specialized training can include: military training, trade and vocational schools, and Job Corps.

Provide details about this training, even if the program was started but not completed. SSA Section 6: Job History List the jobs up to 5 that the applicant has had in the 15 years before he or she became unable to work.

List the most recent job first and do not exclude jobs from the list just because earnings are minimal. If the applicant did not work at all in the 15 years before he or she became unable to work, check the box and go to Section 7 — Medicines. List for each job: Job title: Enter the type of job performed, not the name of the employer. If the applicant does not remember their job title, add a generic title that describes the tasks performed.

Hours per day, days per week, and rate of pay. Check the appropriate Job History box that applies to the claimant: If the applicant had only one job in the last 15 years, answer the rest of the questions in Section 6. If the applicant had more than one job in the last 15 years before he or she became unable to work, do not answer the rest of the questions in Section 6 and go to Section 7.

SSA Section 7: Medicine List all brand name or generic medicines the applicant is taking, including those prescribed by a doctor and any over-the-counter medicines, to treat his or her physical and mental conditions. Provide the name of the medicine, the prescribing physician, and the reason for the medicine i. If possible, collect this information from the prescription s or prescription bottles. If the applicant has been prescribed medication, but is inconsistent in taking it due to symptoms of his or her illness, poor memory, or limited funds, add the medications to section 7 and provide details in the remarks section about the reasons the applicant is not consistently taking the medicine s.

Include information about the use of medical marijuana and the side effects of this treatment SSA Section 8: Medical Treatment Include all medical sources that have examined or treated the applicant for physical or mental conditions, even if they are not recent. It is important to provide comprehensive information in this section, as DDS uses this information to obtain and evaluate medical evidence for the application.

Medical treatment sources can include hospitals, clinics, substance use treatment, and evaluation by other health professionals. Jails and prisons may also be a source of medical records. If the applicant underwent evaluations or treatment while incarcerated, you can add this information to either section 8 or 9. DDS needs to know as many details as possible about the medical provider, including: Contact information: mailing address, fax and phone numbers, treating physician, and patient number Dates of inpatient, outpatient, and emergency room treatment Conditions evaluated: list all mental and physical health conditions evaluated or treated by the provider Type of treatment received.

If more than five doctors or hospitals have treated the applicant, use Section 11 — Remarks and give the same detailed information for each healthcare provider. By providing comprehensive information, you can help ensure that DDS accesses all available medical records to support the application.

For example, individuals aged 18 who have been receiving SSI as children and are undergoing a redetermination to qualify for SSI as an adult.

If this section applies, provide information about any vocational rehabilitation or supportive services the applicant has received. SSA Section Remarks Use this section to collect any additional information or explanation the applicant did not give in other parts of this report.

At the beginning of the remarks, add that this is a SOAR application Document if the applicant is experiencing homelessness and if they had any difficulties completing the form If the applicant did not have enough space in the sections of this report to enter the requested information, use this area for additional information Indicate in remarks which medical records you will be submitting with the application.

For the application to be considered a SOAR-assisted application, case managers must provide all the materials discussed previously, i.

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