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Social Security Call Form

(Field marks with * are required)

* First Name:
Middle Initial:
* Last Name:
* Street address:
* City:
* State:
* Zip:
* Telephone 1:
Telephone 2:
Email address:
* What is your date of birth?:
(mm-dd-yyyy)
Are you a US Citizen?:
Yes
No
Are you a Resident ALIEN?:
Yes
No
* What is your highest year (Grade) of education?:
Are you getting medical treatment now or taking medications?:
Yes
No
* What was the approximate last date of medical treatment or medication prescription?:
(mm-dd-yyyy)
* Briefly describe the medical care you are getting and all the medications you are taking:
Have you applied for Social Security Disability?:
Yes
No
Have you been denied?:
Yes
No
* What was the approximate date of the last denial letter?:
(mm-dd-yyyy)
 
days
* What was the type of denial you received?:

WARNING : The Time Limit to appeal unfavorable decision is 60 days from the date of the denial letter.

Have you applied for Social Security Disability or SSI before and received a denial from which you never took any further action such as appealing?:
Yes
No
Please indicate the year you were denied, the city and state where you applied and why you believed you were unable to work:
* Please describe the medical and or mental conditions that are preventing you form working and the limitations and symptoms you are experiencing. It is important to include all the medical and or mental conditions you have to maximize our chances of winning your case:
What is the maximum weight you are able to lift in pounds?:
Describe any difficulty you have with standing:
Describe any difficulty you have with walking:
Describe any difficulty you have with sitting:
Describe any difficulty you have with concentration:
Are you working now?:
Yes
No
Have you ever worked?:
Yes
No
* When was the approximate last day you worked?:
(mm-dd-yyyy)
Have you worked at least 5 out of the last ten years?:
Yes
No
* Briefly, please describe the occupations performed for the 15 years before you last worked. We are not asking that you list the names of your former employers, we just need to know the type of work you did over the last 15 years before your last date of work:
Briefly, tell us why you believe that you are unable to work?:
SSI SECTION:
Do you have total assets such as cars, bank accounts, land, real estate and investments that total more than $ 2,000?:
Yes
No
Are you living a spouse or a significant other who has total assets such as cars, bank accounts, land, real estates, and investments that total more than $ 3,000?:
Yes
No
Do you and the spouse or significant other you are living with receive combined total income from any source such as but not limited to workers compensation, private disability insurance, veterans pension, dividends, interest, rents, or investment income that is greater than $ 800 each month?:
Yes
No
Are you receiving general relief payments from a county agency?:
Yes
No
Are there any warrants for your arrest?:
Yes
No

Quick Contact

* Name:

* Phone:

* E-mail:

* Date of incident:

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Contact Us

800.GET.SSDI
800.438.7734

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