B.Applying for SSDI or SSI Benefits
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CHAPTER 3 | DISABILITY BENEFITS FOR CHILDREN | 91
Form SSA-3820-BK, Disability Report—Child (Page 1)
Penny A. Reeves
335-67-8901
Marilyn Reeves
4301 West Markham Street
Oklahoma City
OK
PAReeves@yahoo.com
405
555-1111
3
parent/mother
3
3
3
73999
92 | NOLO’S GUIDE TO SOCIAL SECURITY DISABILITY
Form SSA-3820-BK, Disability Report—Child (Page 2)
3
56 in.
80 lbs.
3
3
3
Betty Slocum
300 West Pine Street
Oklahoma City
OK
405
555-1789
Aunt
3
3
73998
CHAPTER 3 | DISABILITY BENEFITS FOR CHILDREN | 93
Form SSA-3820-BK, Disability Report—Child (Page 3)
Intellectual disability
Heart disease from birth
April
14
2009
3
3
3
94 | NOLO’S GUIDE TO SOCIAL SECURITY DISABILITY
Form SSA-3820-BK, Disability Report—Child (Page 4)
Dr. Jessica Cook, psychologist (PhD)
1001 Polk Street
Oklahoma City
November 2009
OK
73888
405 555-1234
January 2016
January 2017
Penny’s intellectual disability
Mental tests (IQ and others); advice about Penny’s behavior and limitations
Dr. John Barrow
95 Capitol Avenue
Oklahoma City
May 18, 2009
OK
73887
July 2016
405 555-3333
July 2017
Evaluation of Penny’s heart problem
Heart surgery to repair defects present at birth
CHAPTER 3 | DISABILITY BENEFITS FOR CHILDREN | 95
Form SSA-3820-BK, Disability Report—Child (Page 5)
Peggy Hall, M.D.
975 Fairview Drive
Oklahoma City
June 2009
OK
73888
October 2015
405 555-4444
October 2016
Regular medical check-ups. Dr. Hall is Penny’s pediatrician
Immunizations, treatment of colds and other problems children have. Also, prescribes drugs
for Penny’s heart condition, consulting with Dr. Barrow.
3
Children’s Hospital
183 Popular Avenue
April 2009
June 2009
Sept. 2009
Sept. 2009
3
Oklahoma City
OK
Once 2009 as above
None
unknown
Penny’s heart had an irregular rhythm and she was short of breath.
Oxygen and drugs to make her heart rhythm regular.
Mostly Dr. Hall, but sometimes other doctors have substituted.
96 | NOLO’S GUIDE TO SOCIAL SECURITY DISABILITY
Form SSA-3820-BK, Disability Report—Child (Page 6)
3
CHAPTER 3 | DISABILITY BENEFITS FOR CHILDREN | 97
Form SSA-3820-BK, Disability Report—Child (Page 7)
3
propranolol
Dr. Hall
irregular heart
feels tired, sleepy
3
Hospital and
office
Dr. Hall
2009
Children’s
Hospital
Dr. Barrow
None
Currently
Fair Park School
School
Yes, forgot date
Dr. Hall’s office
Dr. Hall
Yes, forgot date
Dr. Hall’s office
Dr. Hall
2013
Dr. Cook’s office
Children’s
Hospital
Dr. Cook
Dr. Hall
Children’s
Hospital
Dr. Hall
Children’s
Hospital
Dr. Barrow
2009, 2011 and other dates
None
2009
None
CBC, liver, others
No
No
Heart
MRI 2009, 2012
98 | NOLO’S GUIDE TO SOCIAL SECURITY DISABILITY
Form SSA-3820-BK, Disability Report—Child (Page 8)
3
3
3
3
3
3
3
Community Mental Health Center
1001 Polk Street
Oklahoma City
405
OK
93888
555-6666
Achievement test
IQ test
don’t know
Don’t remember
2013
CHAPTER 3 | DISABILITY BENEFITS FOR CHILDREN | 99
Form SSA-3820-BK, Disability Report—Child (Page 9)
3
1st
Peabody Elementary
2500 Pine Street
Oklahoma City
Polk
405
OK
555-7777
8/2014 - Current
Ms. Harrison
3
IQ
2015
3
Ms. Ramirez
3
Mr. Johnson
93777
100 | NOLO’S GUIDE TO SOCIAL SECURITY DISABILITY
Form SSA-3820-BK, Disability Report—Child (Page 10)
see above
3
CHAPTER 3 | DISABILITY BENEFITS FOR CHILDREN | 101
Form SSA-3820-BK, Disability Report—Child (Page 11)
3
1/11/2016
Penny tires easily, and is frustrated by not being able to learn as fast as other children. Her
teachers say she is falling further and further behind in her school work. Dr. Hall says Penny’s
heart is becoming more irregular and increasing in size. She says Penny needs more tests in the
hospital and might even need surgery again, but we can’t afford the costs. Penny’s doctors and
teachers say they will provide any information requested. Please contact me, Penny’s mother, if
there is any problem obtaining Penny’s medical or school records. Also, I request Penny’s medical
information be evaluated by a real doctor to determine her disability and also that Penny’s
treating doctors’ opinions be considered.
