|
Is this a:
|
Regular Disability CaseSSI CaseBoth
|
|
Date you are telling SSA you became disabled*
|
|
|
Have you already applied for social security disability?
|
YesNo
|
|
If You Have Applied:
|
|
Have you been denied SSA benefits?
|
YesNo
|
|
If You Have Been Denied:
|
What is the date of your last denial?
|
|
|
How many times have you been denied on this application?
|
|
|
|
How many previous applications for SSA disability have you filed?*
|
|
|
Are you currently working?
|
YesNo
|
|
If you have stopped working, what is the date you stopped working?
|
|
|
Which medical conditions or diagnoses are responsible for your disability?*
|
|
|
If you have any MRIs, or other diagnostic imaging, which you believe support your disability claim, please provide the dates and what you believe they showed:
|
|
|
Over the last 15 years, briefly describe all the job types you performed:*
|
|
|
How far did you go in school (including any certifications you have earned):*
|
|
|
Are you currently receiving medical care for all of your disabling conditions?
|
YesNo
|
|
If no, which conditions are you receiving medical care for?
|
|
|
Please list the names of your doctors, how long you have been treated with them, and what medical condition they are treating:*
|
|
|
If any doctors have told you either to apply for disability or said they will support you in a disability case, please provide the doctor’s name and when they told you this:
|
|
|
In your own words, what has occurred to make you seek legal representation in your SSA case?*
|
|
