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Case Sheet
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CLIENT INFORMATION FOR ONLINE CONSULTATION
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Email Address:
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Name:
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Street Address:
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City:
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State:
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Zip:
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Home Phone:
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Cellular Phone:
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Date of Birth:
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MM/DD/YYYY
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Do you speak English fluently?
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Read English?
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Write English?
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If not, what is your main language?
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Marital Status:
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SOCIAL SECURITY DISABILITY CLAIM INFORMATION |
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Have you filed a Disability Claim?
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If so, what type of claim?
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If so, when did you file your claim?
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MM/DD/YYYY |
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If so, was your claim denied?
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If denied, date of last denial?
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MM/DD/YYYY |
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If denied, at what stage was claim denied?
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Have you worked in the last 5 years?
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When did you last work?
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MM/DD/YYYY |
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Why did you stop working?
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DESCRIBE BELOW THE NATURE OF YOUR DISABILITY AND ANY LIMITATIONS WHICH MAY AFFECT YOUR ABILITY TO WORK: |
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WORKERS' COMPENSATION CLAIMS /LONG TERM DISABILITY INSURANCE/ OTHER INJURIES |
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Is your disability related to an injury or activity at work?
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Do you have a workers' compensation claim pending?
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Did you previously have a workers' compensation claim?
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Did you purchase or did your employer provide long term disability (LTD) insurance?
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Did you file an LTD claim?
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If you have an LTD claim pending or denied, what is the status, ie: when was it denied and what is the time limit given to appeal? |
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If you have a public/government disability retirement claim pending or denied, what is the status, ie: when was it denied and what is the time limit given to appeal? |
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