SOCIAL SECURITY DISABILITY INTAKE FORM

Thank you for allowing us to represent you in your claim for disability benefits. In order for us to efficiently process your application or appeal, complete this questionnaire about your medical treatment and work history. Most importantly, this information ensures that all medical records are obtained for your claim.

Please list all testing you have received/completed in the past two years and specify part of the body, if applicable. This includes mri, ct scans, x-rays, nerve testing, blood work and psychology testing.