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Get SSA-3820-BK 2021-2024

Disability Report - Child - Form SSA-3820-BK Fill out as much of this form as you can before your interview appointment. REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM. Form Approved OMB No. 0960-0577 Page 1 of 12 SOCIAL SECURITY ADMINISTRATION Form SSA-3820-BK 03-2017 UF SECTION 1 - INFORMATION ABOUT THE CHILD B. DISABILITY REPORT - CHILD - Form SSA-3820-BK READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM THIS IS NOT AN APPLICATION IF YOU NEED HELP If you need help with this form complete as much of it as you can and your interviewer will help you finish it. HOW TO COMPLETE THIS FORM The information that you give us on this form will be used by the office that makes the disability decision on your disability claim* You can help them by completing as much of the form as you can* DO NOT LEAVE ANSWERS BLANK. If you do not know the answers or the answer is none or does not apply write don t know or none or does not apply. IN SECTION 4 PUT INFORMATION ON ONLY ONE DOCTOR/HMO/THERAPIST/ OTHER/ HOSPITAL/CLINIC IN EACH SPACE* Each address should include a ZIP code. Each telephone number should include an area code. DO NOT ASK A DOCTOR OR HOSPITAL TO COMPLETE THE FORM. However you can get help from other people like a friend or family member. If your appointment is for an interview by telephone have the form ready to discuss with us when we call you. ahead of time if you were told to do so. Be sure to explain an answer if the question asks for an explanation or if you want to give additional information* If you need more space to answer any questions or want to tell us more about an answer please use Section 10 DATE AND REMARKS on Pages 11 and 12 and show the number of the question being answered* ABOUT THE CHILD S MEDICAL AND OTHER RECORDS If you have any of the following records for the child at home send them to our office with your completed forms or bring them with you to the interview. If you need the records back tell us and we will photocopy them and return them to you. The child s medical records Copies of the child s prescriptions or medicine containers The child s Individualized Education Program YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS THAT YOU DO NOT ALREADY HAVE* With your permission we will do that for you. The information we ask for on this form tells us from whom to request medical and other records. If you cannot remember the names and addresses of any of the doctors or hospitals or the dates of treatment perhaps you can get this information from the telephone book or from medical bills prescriptions and medicine containers. Print or write clearly. Privacy Act Statement Collection and Use of Personal Information Sections 205 a 1631 e 1 and 223 d 5 A of the Social Security Act as amended allow us to collect this information* Furnishing us this information is voluntary. However failing to provide all or part of the information may affect the decision on the claim* We will use the information to make a decision regarding if a child is eligible for benefit payments.

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