List EVERY doctor, hospital, and clinic you've seen — SSA will request records

Be specific about what you CAN'T do, not just your diagnosis

Keep a daily symptom diary — it helps with functional assessments

Social Security Disabilityvery hard

Adult Disability Report

SSA-3368-BK · SSA

The most complex patient-facing disability form. 15 pages requiring complete medical history, all diagnoses, medications, treating providers, hospitalizations, and work history.

Form Details

Total fields: 185
Auto-fillable: 140 (76%)
Time without BeneFill: 120 minutes
Time with BeneFill: 25 minutes
Time saved: 95 minutes
Filled by: patient
Frequency: one time

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Where to Submit This Form

🌐

SSA.gov

https://www.ssa.gov/disability/

Start your application online.

📬

Mail to your local SSA office

https://secure.ssa.gov/ICON/main.jsp

Find your local office

🏢

In person at local SSA office

https://secure.ssa.gov/ICON/main.jsp

Required Attachments

📎 Medical records from all treating providers
📎 List of all medications with dosages
📎 Lab results, imaging reports, surgical notes
📎 Statements from doctors about your limitations

Processing Time

3-6 months for initial decision. 60% of initial claims are denied — appeal if denied.

What Happens Next

SSA may schedule a consultative examination (CE). They will request your medical records directly from providers you list.

Tips for This Form

✓ List EVERY doctor, hospital, and clinic you've seen — SSA will request records
✓ Be specific about what you CAN'T do, not just your diagnosis
✓ Keep a daily symptom diary — it helps with functional assessments
✓ If denied, you have 60 days to appeal. Most claims are won on appeal.

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SSA-3373-BK · SSA

10-page functional assessment covering ADL capacity, daily routines, social functioning, cognitive abilities, and physical limitations.

Work History Report

SSA-3369-BK · SSA

10-page report requiring detailed descriptions of all jobs held in the past 15 years including physical demands, tools used, supervision, and lifting requirements.

Authorization to Disclose Information

SSA-827 · SSA

Authorization allowing SSA to collect medical and other information from providers, hospitals, and other sources for disability determination.

Appointment of Representative

SSA-1696 · SSA

Designates an attorney or non-attorney representative to act on the claimant's behalf in SSA disability proceedings.

SSDI Application

SSA-16-BK · SSA

Application for Social Security Disability Insurance Benefits. Requires detailed work history, earnings record, and medical condition documentation.

SSI Application

SSA-8000-BK · SSA

Application for Supplemental Security Income for aged, blind, and disabled individuals with limited income and resources. Must be completed via SSA interview.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the SSA or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.