SSI Facilitation- Forms

Revised on June 10, 2024

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
Interim Assistance Reimbursement Authorization DSHS 18-235

Repayment agreement when state benefits are duplicated by federal benefits.
Consent for Release of Information SSA-3288 DDS Notice. Receive copies of Consultative Exams, disability determination letters, etc.
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).
Application for Supplemental Security Income SSA-8001-F5 Apply for SSI (Title 16 application). SSI Facilitators use a simplified paper form (SSA-8001) in agreement with SSA.

Application for Disability Insurance Benefits

Internet iClaim/i3368

Apply for Social Security Disability (Title 2 application). (The i3368 is connected to the Internet iClaim).
Disability Report- Adult

SSA-3368-BK

 Report client’s medical conditions, employment history, education, and medical treatment.
Application for Disability Insurance Benefits SSA-16-BK Apply for SSDI (Title 2 paper application).
Function Report- Adult SSA-3373-BK Report how client’s condition(s) limit their daily activities.

Work History Report

 SSA-3369-BK

Report client’s vocational information for jobs 5 years prior to becoming unable to maintain substantial gainful activity due to health conditions.
SSI Cover Letter DSHS 02-577
DSHS 02-577A
DSHS 02-577B		 Cover letter for initial application, reconsideration, or hearing packet.
Disability Report- Appeal iAppeal Report used to update client information (medical conditions and medical treatment) for a disability appeal.
Request for Reconsideration SSA-561-U2 Request a reconsideration when denied at the initial determination. (This form is included in the iAppeal).
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).
Appeals Council Request for Review Online AC Appeal Online request for Appeals Council to review an Administrative Law Judge’s decision.
Request for Review of Hearing Decision/Order HA-520-U5 Request for Appeals Council to review an Administrative Law Judge’s decision.
Non-Medical Appeal Non-Medical Appeal Online request for non-medical denial.

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).
Personal Observations Word file Available through your regional team. Intended to capture important details as seen, heard, or experienced during your client interactions.
Social Service Observation Tool DSHS 02-576 Available in Barcode. Intended to capture important details as seen, heard, or experienced during your client interactions.

 

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