SSA-3
|
Marriage Certification
|
Orange
|
HA-L8
|
Letter to Vocational Expert Requesting Attendance at a Hearing
|
Red
|
HA-L9
|
Letter to Medical Expert Requesting Attendance at a Hearing
|
Red
|
SSA-11
|
Request to Be Selected As Payee
|
Orange
|
SSA-16
|
Application for Disability Insurance Benefits
|
Orange
|
HA-L87
|
Response to Request by Claimant or Representative to Change the Time or Place of Hearing
|
Red
|
SSA-L106
|
Letter to Custodian of School Records (Discard upon receipt of requested evidence;
otherwise, move to Blue section.)
|
Green
|
SSA-392
|
Medical Consultant's Review of Residual Functional Capacity Assessment (Physical/Mental)
|
Yellow
(Back)
|
SSA-416
|
Case Analysis
|
Yellow
(Back)
|
SSA-450-SI*
|
SSI Data Input and Determination
|
Orange
|
SSA-454
|
Report of Continuing Disability Interview
|
Blue
|
SSA-455
|
Disability Update Report
|
Blue
|
HA-501
|
Request for Hearing by ALJ
|
Red
|
HA-504
|
Acknowledgment of Notice of Hearing
|
Red
|
HA-520
|
Request for Review of Hearing Decision/Order
|
Red
|
SSA-538
|
Childhood Disability Evaluation Form
|
Yellow
(Back)
|
SSA-546
|
Workers' Compensation/Public Disability Benefit Questionnaire
|
Orange
|
SSA-561
|
Request for Reconsideration
|
Red
|
SSA-632
|
Request for Waiver of Overpayment Recovery or Change in the Repayment Rate
|
Orange
|
SSA-635
|
Waiver Determination
|
Yellow
(Front)
|
HA-649
|
Requests for Consultative Examination and Evaluation (Discard upon receipt of all
requested evidence; otherwise, move to the Yellow (Back) section.)
|
Green
|
SSA-765
|
Response to Notice of Revised Determination
|
Red
|
SSA-769
|
Request for Change in Time/Place of Disability Hearing
|
Red
|
SSA-770
|
Notice Regarding Substitution of Party upon Death of Claimant-Reconsideration of Disability
Cessation
|
Red
|
SSA-773
|
Waiver of Right to Appear–Disability Hearing
|
Red
|
SSA-789
|
Request for Reconsideration-Disability Cessation
|
Red
|
SSA-795
|
Statement of Claimant or Other Person (Non-Disability)
|
Orange
|
SSA-795
|
Statement of Waiver of Advance Notice of Disability Hearing
|
Red
|
SSA-795
|
Statement of Claimant or Other Person (Disability Related)
|
Blue
|
SSA-820
|
Work Activity Report (Self-Employed Person)
|
Blue
|
SSA-821
|
Work Activity Report (Employee)
|
Blue
|
SSA-827
|
Authorization for Source to Release Medical Information to SSA (Not dated or dated
within the last 6 months. It is imperative to purge expired SSA-827s from the file.)
|
Blue
|
SSA-831
|
Disability Determination and Transmittal (with rationale)
|
Yellow
(Front)
|
SSA-832
|
Cessation or Continuance of Disability or Blindness Determination and Transmittal
(with rationale) Title XVI
|
Yellow
(Front)
|
SSA-833
|
Cessation or Continuance of Disability or Blindness Determination and Transmittal
(with rationale) Title II
|
Yellow
(Front)
|
SSA-847
|
SSA Request for Case Action
|
Blue
|
SSA-882
|
Report of Field Review of Continuing Disability
|
Blue
|
SSA-887
|
Summary of Evidence
|
Blue
|
SSA-888
|
Reconsideration/Disability Hearing Procedures
|
Red
|
SSA-899
|
Continuing Disability Review (CDR)
|
Blue
|
SSA-L991*
|
Supplemental Security Income Information
|
Orange
|
SSA-1128
|
Representative Involved (Staple to Bottom Right Corner–Front of File)
|
|
SSA-1129
|
Attorney Fee Case-Past Due Benefit Summary
|
Yellow
(Front)
|
SSA-1203
|
Determination of Benefits Payable After Offset
|
Yellow
(Front)
|
SSA-1204
|
Disability Hearing Officer's Report of Disability Hearing (DC)
|
Red
|
SSA-1205
|
Disability Hearing Officer's Report of Disability Hearing
|
Red
|
SSA-1207
|
Disability Hearing Officer's Decision
|
Red
|
SSA-1272
|
Subpoena-Disability Hearing
|
Red
|
SSA-1560
|
Petition For Authorization To Charge And Collect A Fee For Services Before The Social
Security Administration
|
Red
|
SSA-L1674
|
Disability Hearing Decision Cover Letter-without benefit continuation
|
Red
|
SSA-L1675
|
Disability Hearing Decision Cover Letter-Benefit Continuation Elected at Reconsideration
and offered again at ALJ Hearing Level
|
Red
|
SSA-L1677
|
Disability Hearing Decision Cover Letter-Benefit Continuation Not Elected at Reconsideration
and Offered Again at ALJ Level
|
Red
|
SSA-L1678
|
Disability Hearing Decision Cover Letter-Without Payment Continuation
|
Red
|
SSA-L1679
|
Disability Hearing Decision Cover Letter-Payment Continuation Not Elected at Reconsideration
and Offered Again at ALJ Hearing Level
|
Red
|
SSA-L1680
|
Disability Hearing Decision Cover Letter-Payment Continuation Elected at Reconsideration
and Offered Again at ALJ Hearing Level
|
Red
|
SSA-1696
|
Appointment of Representative
|
Red
|
SSA-1709
|
Request for Workers' Compensation/Public Disability Benefit Information
|
Orange
|
SSA-1719s*
|
SSI Postentitlement Direct Input (Discard)
|
|
SSA-1774
|
Request for Corrective Action (Consistency Review)
|
Blue
|
SSA-2506
|
Psychiatric Review Technique (PRT) Form Completed by DDS Physician or by Treating
Physician
|
Yellow
(Back)
|
SSA-2514
|
Record of Claimant's Intent to File
|
Orange
|
SSA-2640
|
Disability Hearing Case
|
Red
|
SSA-3023
|
Medical Consultant's Review of Psychiatric Review Technique Form
|
Yellow
(Back)
|
SSA-3033
|
Employer Work Activity Questionnaire
|
Orange
|
SSA-3288
|
SSA Consent for Release of Information
|
Orange
|
SSA-3367
|
Disability Report (Field Office)
|
Blue
|
SSA-3368
|
Disability Report–Adult
|
Blue
|
SSA-3369
|
Work History
|
Blue
|
SSA-3371*
|
Pain Report Child
|
Blue
|
SSA-3373
|
Function Report (Adult)
|
Blue
|
SSA-3375*
|
Function Report (Child – Birth to 1st Birthday)
|
Blue
|
SSA-3376*
|
Function Report (Child – Age 1 to 3rd Birthday)
|
Blue
|
SSA-3377*
|
Function Report (Child – Age 3 to 6th Birthday)
|
Blue
|
SSA-3378*
|
Function Report (Child – Age 6 to 12th Birthday)
|
Blue
|
SSA-3379*
|
Function Report (Child – Age 12 to 18th Birthday)
|
Blue
|
SSA-3380
|
Function Report (Adult – Third Party
|
Blue
|
SSA-3441
|
Disability Report-Appeal
|
Blue
|
SSA-3820
|
Medical History and Disability Report (Child)
|
Blue
|
SSA-3881
|
Questionnaire for Children Claiming SSI Benefits
|
Blue
|
SSA-3885
|
Government Pension Questionnaire
|
Orange
|
SSA-L4201
|
Letter to Employer Requesting Wage Information
|
Orange
|
SSA-4268
|
Explanation of Determination (Attached to notice)
|
Red
|
SSA-4268
|
Explanation of Determination (Attached to SSA-831–Disability Determination Transmittal)
|
Yellow
(Front)
|
HA-4632
|
Claimant's Medications
|
Blue
|
SSA-4734
|
Physical Residual Functional Capacity (RFC) Assessment – (Completed by DDS Physician)
|
Yellow
(Back)
|
SSA-4734-Sup
|
Mental Residual Functional Capacity (RFC) Assessment – (Completed by DDS Physician)
|
Yellow
(Back)
|
SSA-4814
|
Medical Report on Adult with Allegation of HIV Infection
|
Yellow
(Back)
|
SSA-4815
|
Medical Report on Child with Allegation of HIV Infection
|
Yellow
(Back)
|
SSA-5002
|
Report of Contact (Non-Disability; e.g. P.O.A., AUX INFO)
|
Orange
|
SSA-5002
|
Report of Contact (Non-Medical; e.g., ADL, School Report)
|
Blue
|
SSA-5002
|
Report of Contact (Disability Related; e.g., Lab Findings From T/P)
|
Yellow
(Back)
|
SSA-8000,* SSA-8001*
|
Application(s) for Supplemental Security Income
|
Orange
|
SSA-8006*
|
Statement of Living Arrangements, In-kind Support and Maintenance
|
Orange
|
SSA-8010*
|
Statement of Income and Resources
|
Orange
|
SSA-8011*
|
Statement of Household Expenses and Contributions
|
Orange
|
SSA-8019*
|
Third Party Liability Information Statement
|
Orange
|
No form number
|
Electronic Disability Collect System (EDCS) Routing Form
|
Blue (filed by DDS)
|
(This is a report. No form number is assigned.)
|
Report of Investigation (CDI)
Place this report on top of ALL documents, including the DDS worksheet.
|
Yellow (Back)
|