Today's Date:
(ALL dates in mm-dd-yyyy format)
Name of Applicant:
Age:
Sex:
Marital Status:
Phone Number:
Address of applicant:
E~mail:
Education:
Name of third party:
Their Address:
Their Phone Number:
Their E~mail (if applicable):
Relationship to 3rd party:
Date of disability:
What are your diabilities:
When date did you last apply for disability Benefits?
When did you receive your denial letter?
Have you applied for reconcideration?
Have you received a reconsideration decision?
Do you have a copy of your denial letter?
Name of duties of past work, most recent first:
Name, address, phone numbers & dates of doctors seen since you were denied:
Name, address and dates & phone numbers of hospitalizations since you were denied:
Is your condition worse, better or same?
If worse, please explain:
Has the impairment effected your mental state in ANY way?
If so, please explain:
Any additional or new medical problems?
Best time to reach you (specify am/pm):
Between and
Hit "Send" ONCE, please.
This
form shows you we have recieved your application when it
takes you to another webpage when you hit "Send". If you do
not get rerouted, please inform us via
email
At the time of hire, we will need your Social Security number.
We can not work without it. You will be asked when we get in touch.
Thank you; LHSS Services
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