Social Security Disability Benefits

Nationwide Social Security Disability Representation

If you have

If one or more of these disabilities keeps you from working, you may be eligible for SSA disability benefits.

We invite you to complete the free Claim Evaluation Questionnaire on this page to allow us to evaluate your situation and advise you of the best alternative for obtaining your SSA disability benefits.

Or Contact us today to directly discuss your situation with one of our experienced advocates.

Thank you for visiting our Claim Evaluation Questionnaire page. If you choose to provide the information requested below in our questionnaire, you will allow us to evaluate your situation and advise you of the best alternative for obtaining your SSA disability benefits.

ABOUT MYSELF AND HOW TO CONTACT ME
Name
Address1
Address2
City
State
Zip
Day Phone
Night Phone
Email Address
Be sure to include your email address immediately above or we cannot provide an email response of our own. Or, type, "Call me soon" in the email area above if you wish to be contacted directly.

ABOUT MY CIRCUMSTANCES
Age	I am years old
Birthday	I was born on (mm/dd/yyyy)
Gender	Male Female
Marital Status:	Married Divorced Separated Single
Level of Education	Grade: 1-7 8-11 12-14 15-18
Work History	I have worked at least 5 of the last 10 years Yes No
My Work Status	I am currently working Yes No
Work Stop Date	I stopped working on (mm/dd/yyyy)
Reason I Stopped Work	Due to the severity of my symptoms Due to being laid off
Work Description	Describe your job at the time your impairment(s) stopped you from working. Include any other work you have performed over the past fifteen years.
Medical Treatment	I see my doctor(s) at least every 3 - 6 months Yes No
Last Appointment	The last appointment with my doctor(s) was (mm/dd/yyyy)
Medical Insurance	I currently have medical insurance Yes No
Number Of Doctors	Total number of doctors I see at this time for my disabilities
Limitation 1	I use a prosthesis Yes No
Limitation 2	I have difficulty walking and/or standing Yes No
Limitation 3	I have difficulty sitting Yes No
Limitation 4	I have difficulty using my hands Yes No
Disabilities	List each of your disabilities that have been medically diagnosed. (For example: Arthritis, DDD, Emphysema, Lupus, Bipolar, Heart Condition, etc.) 1. (If more than four disabilities, continue listing 2. disabilities in the fourth box, separating each 3. with a comma) 4.
Medical Providers I See For Each Impairment	Please provide the name of your medical providers (M.D., D.O., PA, Therapist, Ph.D.) and the disabilities above they treat. (For example: John Smith, M.D. - Lupus, Bill Jones, Ph.D. - Bipolar, etc.) 1. (If more than four medical providers, 2. list the additional ones in the fourth 3. box separating each with a comma) 4.
Symptoms	Describe the symptoms you experience for each disability above, including your estimation of the severity and duration of the symptoms. (For example: My degenerative disc disease causes pain (very severe and constant), fatigue (chronic and every day), and depression (mild, with medication, but everyday) and my emphysema causes shortness of breath (severe, constant).
A Brief History And Current Status Of My Disability	Describe the onset (cause) and circumstances related to your disabilities and the time frame they occurred.
Why My Disability Or Disabilities Keep Me From Working.	Describe the specific reasons why you believe your disabilities will or have stopped you from working and why they will continue to keep you from working.

ABOUT MY SSA DISABILITY BENEFIT CLAIM

The questions below indicate whether or not you have previously filed a disability claim
or if you recently filed for and have a current disability claim in process
and the status of that claim.

I Have Filed A Previous Claim But It Was Denied And I Did Not Appeal

I Have Never Filed A Claim ( mm/dd/yyyy) (Use this date format in the fields below)

I Have Filed And Claim Is In Process Date of Application

My Initial Application Was Denied Date Initial Application Was Denied

I Filed A Reconsideration Appeal Date of Request For Reconsideration

My Reconsideration Was Denied Date Reconsideration Was Denied

I Filed An ALJ Hearing Appeal Date of Request For Hearing

My Hearing Is Not Yet Scheduled

My Hearing Has Been Scheduled Scheduled Date of Hearing

When you have completed all three sections of the form above, please scroll back to the
top of the form and carefully review your entries. When you are satisfied that all entries
meet with your approval, please fill in the Security Code below and click the Submit button.

Ready ? Ok, but before you click 'Submit' please insert the same letters and numbers you see in this image into the box to your right -> :

Top of Page