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Social Security Disability Advocacy

Online Application

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Online Application


Please complete the following application to the best of your ability. If you are uncertain on how to answer any specific question, please make note and inform your advocate when they contact you.

Your private information is safe and secure with DAOA. We will never share or sell your personal information! To learn more, please read our Privacy Policy.


General Applicant Information

(Information about the individual applying for disability benefits.)

Applicant Name * - required
First
Last

Address
City
State

Zip Code
County
Telephone
Alternate Phone
Fax
Email - If available, please include your email address for faster response.

I do not have email, contact me by phone instead

Age

Date of Birth (mm/dd/yyyy)

Place of Birth
City:
State:

Mothers Maiden Name
Gender: Male Female

Marital Status
Married Divorced Separated Single

What is the best time to contact you?


Contact Person Information

(A person who knows how to contact you at all times)

Relation: The applicant is my
Contact Name
First
Last

Address

City
State


Zip Code
Email
Telephone


Applicant Education Information
Education Level
Have you ever attended special education classes?
Yes No
If "Yes", please describe

Have you participated in any work, job training or vocational rehabilitation programs?
Yes No
If "Yes", please describe


Applicant Work Information
Work History
I have worked at least 5 of the last 10 years
Yes No
Are you Currently Working?
Yes No
if No, when did you stop? (mm/dd/yyyy)

My Work Classification (see below for description)
Sedentary - Lift max 10lbs, sit 6-8hrs/day, stand 2-8hrs, never crouch, rarely kneel, full use of hands. Light - Lift max 20lbs, 10 frequently, stand 6-8hrs, occasional sitting, occasional stooping, never crouching, some kneeling. Medium - Lift max 50lbs, 25 frequently, stand 6-8hrs, frequent stooping, crouching, some kneeling, some climbing. Heavy - Lift 100lbs occasionally, 50 frequently, stand 6-8hrs, frequent stooping, crouching, kneeling, pushing/pulling.
Work Description
Briefly describe your most recent work as well as 15 years in the past (if applicable).


Applicant Medical Information
Disabling Condition
Briefly describe your disabling condition and the symptoms you experience due to your disabling condition.
Has your disability lasted at least one year?
Yes No

Will it last another 12 months?
Yes No

Medical Treatment
I see my doctor(s) at least every 3 to 6 months
Yes No

Last Appointment (mm/dd/yyyy)
The last appointment with my primary doctor was
Medical Insurance

I currently have medical insurance
Yes No

Number of Doctors
The total number of doctors I see at this time for my disabilities is

Since Stopping work, is your condition?
Better Same Worse
If "Worse", how?

Specialists Seen
Please list any and all specialists seen for your disabling condition

Medical Tests
What medical tests have you had or are going to have in the future?

Medications
List any and all medications you are taking for your disabling condition

Medication Side Effects
List any and all medication side effects you are experiencing

Pain Conditions
List any and all conditions that causes you severe pain

Rate Your Pain (1/10=Slight Pain | 9/10=Extreme Pain)
With Medications / 10  
Without Medications / 10

Limitation 1
I have difficulty walking and/or standing
Yes No

Limitation 2
I have difficulty sitting
Yes No

Limitation 3
I have difficulty using my hands
Yes No


Applicant SSA Claim Status
Current Status of SSA Disability Claim, if Applicable
(Your answers to the questions below indicate whether or not you have previously filed an SSA disability claim or if you have recently filed for and have a current SSA 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
I have filed a claim and it is in process

Date of Application (mm/dd/yyyy)

My initial application was denied
Date Initial Application Was Denied (mm/dd/yyyy)

I have a copy of my "Notice of Disapproved Claim"...
Yes No
Reason for Denial of Initial Claim
I filed a Reconsideration Appeal
Date of Request For Reconsideration (mm/dd/yyyy)
My Reconsideration was denied
Date Reconsideration was denied (mm/dd/yyyy)

I have a copy of my "Notice of Reconsideration"...
Yes No
Reason for Denial of Consideration
I filed an ALJ Hearing Appeal
Date of Request For Hearing (mm/dd/yyyy)
My Hearing is not yet scheduled
My Hearing has been scheduled
Scheduled date of Hearing (mm/dd/yyyy)


Other - Referral Information
Name of Referral Person
First
Last

Name of Referral Organization
How did you hear a bout us?
Google Yahoo MSN Person Other

If "Other", please describe


Be sure to review your application before submitting. Please press "submit" only once.


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WE DON'T GIVE UP... AGAINST ALL ODDS, WE WIN DISABILITY CLAIMS!

AN EXPERIENCED ADVOCATE WILL WORK CLOSELY WITH YOU TO MAKE SURE THAT YOU WIN THE DISABILITY BENEFITS THAT YOU DESERVE!