OIG iClaims Focus Group Handouts

noco t p i kS

 


www.socialsecurity.gov


  
Home

Questions ?

Contact Us

Search

GO

Apply Online for Disability Benefits
Apply
Online for
You can start your disability claim immediately. There is no Disability
need to wait for an appointment;
Benefits

Applying online for disability benefits offers several advantages:

You can apply from the convenience of your own home or
on any computer; and
You avoid trips to a Social Security office, saving you time
and money.
You can use the online application to apply for benefits if you:
are age 18 or older;
have worked and paid Social Security taxes long enough to
qualify;
More Information
Social Security
Disability Planner
Disability Benefits
Information for
Representatives

More Helpful Health Care
Information
Health Information from the
U.S. Department of Health
and Human Services

have a medical condition that has prevented you from
working or is expected to prevent you from working for at
least 12 months or end in death; and
reside in the United States or one of its
territories/commonwealths.
Please note: If you want to apply for disability benefits for a child,
go to Applying for Disability Benefits for Children.
If your application has recently been denied, the Internet Appeal
is a starting point to request a review of our decision about your
eligibility for disability benefits.

Follow these 4 easy steps to apply online

www.healthfinder.gov

Step 1. Review the Adult Disability Checklist for details about
what you will need before starting the online process.

Prescription Drug
Assistance Programs

Step 2. Fill out the online Disability Benefit Application to provide
us with information regarding eligibility for payment.

www.healthfinder.gov/rxdrug

Step 3. Fill out the online Adult Disability Report to provide us
with medical and work history.
Step 4. Fill out, sign and mail or take the Authorization to
to
Disclose Information to the Social Security Administration
 
 Security



6RFLDO6HFXULW\2QOLQH

%HQHILW$SSOLFDWLRQ

ZZZVRFLDOVHFXULW\JRY

:HOFRPHWRWKH6RFLDO6HFXULW\%HQHILW$SSOLFDWLRQ
)RUP$SSURYHG20%1R([SLUHV 

7KDQN\RXIRUXVLQJRXURQOLQH'LVDELOLW\
DSSOLFDWLRQ

%HIRUH\RXEHJLQ
%HIRUH\RXVWDUWDSSO\LQJIRUEHQHILWV\RXVKRXOG
UHDG8VLQJWKLVDSSOLFDWLRQLQRUGHUWRXQGHUVWDQG
WKHLQIRUPDWLRQDQGGRFXPHQWVWKDWPD\EH
QHHGHG
>

,QLWLDO,QIRUPDWLRQ6HFWLRQ3DJHRI

$SSOLFDQW,GHQWLILFDWLRQ
$SSOLFDQW
V1DPH

6 "-'(  "-  "(-'"-(-
 
- 

- -(-
First Name

Middle Name



Last Name



Suffix





6RFLDO6HFXULW\1XPEHU
! 

*HQGHU
0DOH 

)HPDOH

'DWHRI%LUWK
Month

Day



Year





'XULQJWKHODVWPRQWKVKDYH\RXEHHQXQDEOHWRZRUNEHFDXVHRI
LOOQHVVHVLQMXULHVRUFRQGLWLRQVWKDWKDYHODVWHGRUDUHH[SHFWHGWRODVWDW
OHDVWPRQWKVRUFDQEHH[SHFWHGWRUHVXOWLQGHDWK"2(

>

 



  

ZZZVRFLDOVHFXULW\JRY



Identification

General

Initial Information

Other Benefits

Remarks

Application Number

Review

Submit

Next Steps

Additional Information

<< [P]revious

[N]ext
>>


,QLWLDO,QIRUPDWLRQ6HFWLRQ3DJHRI

&RQWDFW,QIRUPDWLRQIRU-RaQ3XEOLF
860DLOLQJ$GGUHVV
Street Address 1


Street Address 2


Street Address 3


Street Address 4


City

State



ZIP





'R\RXOLYHDWWKLVDGGUHVV"
>

 



  

ZZZVRFLDOVHFXULW\JRY



Identification

General

Initial Information

Other Benefits

Remarks

Application Number

Review

Submit

Next Steps

Additional Information

<< [P]revious

[N]ext
>>


,QLWLDO,QIRUPDWLRQ6HFWLRQ3DJHRI

%LUWKDQG&LWL]HQVKLS,QIRUPDWLRQIRU-RaQ3XEOLF
:HUH\RXERUQLQWKH8QLWHG6WDWHVRUD867HUULWRU\RU&RPPRQZHDOWK"
2(

>

 



  

ZZZVRFLDOVHFXULW\JRY



Identification
Initial Information

General

Other Benefits

Application Number

Remarks

Review

Submit

Next Steps

$SSOLFDWLRQ1XPEHU
Application
Number

Additional Information

<< [P]revious


[N]ext
>>

$SSOLFDWLRQ1XPEHU6HFWLRQ3DJHRI

$SSOLFDWLRQ1XPEHUIRU-RDQ3XEOLF
0' """
"- -\RXU+" ,-  -(3 (*1-' (
 -(,&'(, (,"-"- - ((-  -(

##% "-'

  -
-'"  -(2(-"
>##%.1"--'"*(  -(,RU\RXPD\ORVH
6RFLDO6HFXULW\EHQHILWV2
-'" -
"(-'1)("  ' .1
"--'"*(  -(,-'
1(*,"("" 

(- 
-2(

2" 
 * -' -"(-'
 (-"-1'' -( ( ""-" (1'  *4.
,('  " ,-(
 -( ,--'

2* . " 
-' '-.
(- 
-2(
2
(-(-
 (

2  -((-
  -(1-'",
RU\RXPD\ORVH66,EHQHILWV2
-'" -
"(-'1)("
 ' .1"--'"*(  -(,-'
1(*,"("" 
7 " -??%%$<&&0$%4??=-  (* ( (-(--



20FDQQRW 


2-'2(-(-
2
( """- (. " " -??%%$<&&0$%4??=

(
 -(
[S]ign Off (finish this later)

<< [P]revious

[N]ext >>

Go

 



  

ZZZVRFLDOVHFXULW\JRY



Identification

General

Other Benefits

Remarks

Review

Submit

Next Steps
Benefit
Information
%HQHILW,QIRUPDWLRQ



Benefit Information

<< [P]revious

[N]ext >>

%HQHILW,QIRUPDWLRQ6HFWLRQ

%HQHILW,QIRUPDWLRQIRU-RaQ3XEOLF
6XSSOHPHQWDO6HFXULW\,QFRPH66,
&'

2*  ",(
-"- *4 (,(" , -"
(41'' -( (""2(


+DYH\RXUHFHQWO\DSSOLHGIRU6XSSOHPHQWDO6HFXULW\,QFRPH"
>

Go

 



  

ZZZVRFLDOVHFXULW\JRY



Identification

General

Benefit Information

Other Benefits

Remarks

Review

Submit

Next Steps
Ability
To Work
$ELOLW\7R:RUN

Disability Questions

<< [P]revious

[N]ext
>>


'LVDELOLW\4XHVWLRQV6HFWLRQ3DJHRI

$ELOLW\7R:RUNIRU-RDQ3XEOLF

3OHDVHOLVWWKHLOOQHVVHVLQMXULHVRUFRQGLWLRQVWKDWOLPLWDELOLW\WRZRUN
2(

2((- -( (-("

$UHWKHVHLOOQHVVHVLQMXULHVRUFRQGLWLRQVUHODWHGWRZRUNLQDQ\ZD\"
>

Go

Social Security Online

Benefit Application

www.socialsecurity.gov
Identification

General

Benefit Information

Other Benefits

Remarks

Review

Submit

Next Steps
Go

Dependents
Dependents

Disability Questions

<< [P]revious

[N]ext >>

Disability Questions Section (Page 3 of 4)

Dependents for Joan Public
Parents
Do you have a parent who receives one-half support from you?
Yes

No

First Parent's Name
First Name

Middle Name

Last Name

Suffix

First Parent's Address
Street Address 1
City

State

ZIP

Do you have another parent who receives one-half support from you?
Yes

No

[S]ign Off (finish this later)

<< [P]revious

[N]ext >>

 



  

ZZZVRFLDOVHFXULW\JRY



Identification

General

Other Benefits

Remarks

Review

Submit

Next Steps
Overall
Summary
2YHUDOO6XPPDU\

Overall Summary

<< [P]revious

[N]ext
>>


2YHUDOO6XPPDU\6HFWLRQ3DJHRI

2YHUDOO6XPPDU\IRU-RDQ3XEOLF
&'" *"'1" -'9"-(" ( ("1"A2
(- )
' (*"."--'; -;,--(--(--' - -
-'  -(&-(--'
 
 . ""--':1- ,-';:-(-
 ;,--(

,GHQWLILFDWLRQ7DE
,QLWLDO,QIRUPDWLRQ6HFWLRQ
Edit

$SSOLFDQW,GHQWLILFDWLRQ3DJH
 (-  -RDQ43XEOLF

 
-, 
@( )HPDOH
+ -
-' -XO\
+(*-' "->(-'".( ,-1), "
(""".(E"
(-("-' -'  "- !-- "- - "-%(-'" (,
!--"-( -'
>

Go

 



  

ZZZVRFLDOVHFXULW\JRY



Identification

General

Other Benefits

Remarks

Review

Submit

Next Steps
Send
this application
6HQGWKLVDSSOLFDWLRQ

Send this application

<< [P]revious


Sign
 Now

6HQGWKLVDSSOLFDWLRQ6HFWLRQ3DJHRI

6HQGWKLVDSSOLFDWLRQIRU-RDQ3XEOLF
To return to the Overall Summary, please use the "Return to Summary" button.
7(* - -(".AE"- ,- --  -(
" ,-
,(
-"
6 "  ( --'
1(*"- -(--
("'-'  -(2
 
'(*"(---'  -(.-'(-' -"(("-  (
--'"- -(-"
2("- ( ( *-' -  -(1,"*(-( ,"-(*
;6LJQ1RZ;,12 "("- (-' --("*( - ("-' -2(-(-


,(
-" (' -'
 
-("- -(1-'  -
(
 -(2 (( -
E-' -2' ! ( -'(
 -(
(-'"  -( (-"- (---',"-
)(1*2("- (
-' - ((1')(1(**" 
"" (*"- -(- ,-  - 
(-'"-(  -(. """("-".-"  (
 ,"(--"( 
-'( -".,-'
3'("-;6LJQ1RZ;.1,"((*-(
 -(
-( --'
 
-("- -(01((*, ,-' (*
(
 -(
[S]ign Off (finish this later)

<< [P]revious

 Now
Sign

Go

Social Security Online

Benefit Application

ZZZVRFLDOVHFXULW\JRY



Identification
Receipt

General

Other Benefits

Remarks

Review

Submit

Next Steps

What's Next?

[N]ext >>

5HFHLSW6HFWLRQ3DJHRI

(YLGHQFHDQG5HFHLSWIRU-RDQ3XEOLF
0,(
-  -(1 "(F%.% ->> 
6(--'" *2-"("--("(1' -(-(1
3 ((--""(*
 (-1'  (
 
(-"
'RFXPHQWV>

Social Security Online

Benefit Application

ZZZVRFLDOVHFXULW\JRY



Identification
Receipt

General

Other Benefits

Remarks

Review

Submit

Next Steps

What's Next?

<< [P]revious

Continue to Adult Disability Report

:KDW
V1H[W"6HFWLRQ3DJHRI

:KDW
V1H[WIRU-RDQ3XEOLF

&' ()
-(*(
-'-'"-"(-'+" ,- -(6""
6(--'" *2-"("--("(1' -(-(1

7RILQLVKWKH'LVDELOLW\$SSOLFDWLRQ3URFHVVFOLFNRQWKH&RQWLQXHWR$GXOW
'LVDELOLW\5HSRUWEXWWRQWRFRPSOHWHWKHIROORZLQJWZRVWHSV
 7--'-+" ,-:-<

$$=. (
%
*( ("(-' : ".-'D -(-+""2(
 -(-
-'
 
-("- -(<

%?=

&KHFNWKH6WDWXVRI\RXU$SSOLFDWLRQ
&'7(
 -(,
-'" "31152722
6 "* -'"(, 
2-A"-')-  -((
 -(
 

-"1QHYHU ")
7(
 -(,
6 "1 - - "-4,"("" "
- ,
')  -(
"- -"F"-*--'
 
-7 " * -'--##111" "-*.
"-&KHFNWKH6WDWXVRI

2IJ :
6:2@.+%$
Continue to Adult Disability Report

Social Security Online

Adult Disability Report

ZZZVRFLDOVHFXULW\JRY

:HOFRPHWRWKH6RFLDO6HFXULW\$GXOW'LVDELOLW\5HSRUW
4? !" #$#%%

&' ()
-(* -
((
 -(

 
-,(
-"2
 
(*
" ,-,(
-".11(
-( (
 -( ,-"( .
 .1). ( -('"-&- .11 ")- -"
(
 -(  (-(-'
-' -
 -

7R6WDUW7KH5HSRUW
2
1 (--"- - (1+" ,-:-.
"
--'("--("(51-'":3)"
✔

,KDYHUHDGWKH3ULYDF\$FW6WDWHPHQW
Start Report

%HIRUH\RXEHJLQ

"- --'"-."' 51
-'":-3)"(-("- (-'
(
 -( ((-"-' - ,(
0  "1 (--1-'
1(* -
()"
2(
 -(,-&'"2(-(-:
 2("--("(/""
51-((-'":51-' -(6""3)"
+" ,-2(
 -(

 
-A"+
(-(
+" ,-
513 ) +" ,-+"(
2(
 -( ,-
 
-A"+" ,-
6* "
-'3 "&7-&'+" ,-
:I*  (

 2(
 -(
2(-(-
-6
3,"-6"8-'2- (2(
 -(

 
-"",-6
3"- --' --1- ) ! -(-"- -'("--(".* -'-'
-". (
("1-'9"-(".,--'"1((-'(,
9"-("(- ("1
(
 -( ,-"- -".*--'6 1):-(-

Social Security Online

Adult Disability Report

ZZZVRFLDOVHFXULW\JRY



Joan6,!!! !!$
Overview

Identification

Report Completer

Medical

Work/Education

Personal Information

Reentry Number

Remarks

Review

Submit

Other Contact

<< [P]revious

3HUVRQDO,QIRUPDWLRQ
6 "-" ,-"


*HQGHU
)HPDOH 

0DOH

&RQWDFW,QIRUPDWLRQ
$GGUHVV
Street Address 1


Street Address 2


Street Address 3


Street Address 4


City

State



Select
6HOHFW

ZIP



'D\WLPH3KRQH1XPEHU
Phone Number

Extension





,VWKHUHDQRWKHUQXPEHUZKHUHZHPD\UHDFK\RX"
>

+DYH\RXXVHGDQ\RWKHUQDPHVRQPHGLFDORUHGXFDWLRQDOUHFRUGV"
! " (( .-' ( .()( 
>


Social Security Online

Adult Disability Report

ZZZVRFLDOVHFXULW\JRY



Joan6,!!! !!$
Overview
Report Completer

Identification

Medical

Personal Information

Work/Education
Reentry Number

Remarks

Review

Submit

Other Contact

<< [P]revious

[N]ext
>>


 &(
 
-, (:(-,"'1( ,
,I\RXORVH\RXU5HHQWU\1XPEHUEHIRUH\RXVXEPLWWKHUHSRUW\RXZLOOQRWEH
DEOHWRJREDFNWRWKLVUHSRUWDQGILQLVK0 ("- - (1- (11*
 (1:(-,.,- 
-'(
 -("(-1,
"-
 
-"1(-, ,- "":(-,
&'"-" -
-'" ,-  -("" (1"-' -- )
 "(0 ORVH6RFLDO6HFXULW\EHQHILWV
1(--'"
- ( (  -(,#%#%
-' ",---'"-.11
*-'-(--
 

 
-,(
-"((
[S]ign Off (finish later)

<< [P]revious

[N]ext >>

Joan Public xxx-xx-0103













Social Security Online

Adult Disability Report

www.socialsecurity.gov

Joan Public xxx-xx-0103
Overview
Conditions

Identification
Doctors

Medical

Work/Education

Hospitals/Clinics

Tests

Remarks

Medicines

Review

Submit

Other Records

Done with this Doctor

Doctors and Other Healthcare Professionals
Remove this Doctor

Doctor/Healthcare Professional Details
Name of Doctor/Healthcare Professional: More Info
Prefix

First Name

Last Name

Suffix

Dr.
Dr.

Office Name or Clinic, if applicable:
Doctor/Healthcare Professional's Address:
If you don't have the full street address, give us as much as you can.
Example: "On Main St next to the Courthouse"
Country
United
States
of America
United
States
of America

Street Address 1
Street Address 2
Street Address 3
Street Address 4
City

State

ZIP

Select
Select

Doctor/Healthcare Professional's Phone Number:
United States of America

International

Include area code.
U.S. Phone Number

Extension

Patient ID Number, if known:

(Continue Onto Next Page)

7UHDWPHQW'DWHVZLWKWKLV'RFWRU+HDOWKFDUH3URIHVVLRQDO
6 "*"-'""- -<"= (,

)LUVWYLVLW
/DVWYLVLW
1H[WYLVLW

I , ()
( (-(-"'

7HVWV2UGHUHGE\WKLV'RFWRU+HDOWKFDUH3URIHVVLRQDO2(

+DVWKLVGRFWRUKHDOWKFDUHSURIHVVLRQDORUGHUHGDQ\WHVWVIRU\RX"
&'"(" ( -"-"' ' 1' 
>


3ULQWLQJ,QVWUXFWLRQV
'R\RXKDYHDZRUNLQJSULQWHUULJKWQRZ"
  ,(*-'7
'- ("*( ( - : "--'
 
 
-

"-,1+&- )-'"
"--
%
2
  ' "
 ". ("(,(*-'-"1-'
-'7
'- ( : "
51.1(-(-' -
 ",""(
-'"-,9"-(* ""
3 (-'"


,I\RXKDYHSULQWLQJSUREOHPV
6 "- * (2
"- ( ,-(-.(-((7(- -
 
- -' "" ('((,"- ,--"-' -(-(--' 
 "

[S]ign Off (finish later)

<< [P]revious

[N]ext >>

Social Security Online

Adult Disability Report

www.socialsecurity.gov

Cover Sheet

<< [P]revious

[N]ext >>

Print this page...
I have completed the Adult Disability Report online.
I understand that the full Adult Disability Report that I completed over the Internet and
sent to SSA electronically will be used in making a decision on claim for disability
benefits.
Joan Public's address is:
Line 1
BALTIMORE, MD 21244
Joan Public's phone number is:
123-332-1331
Name and address of someone else SSA can contact who knows about Joan
Public's condition:
Jessica Biehl
Line1
Concord, MD 21228
I have attached the following items:
(Check all that apply.)
_____ Medical Release SSA-827 Form
_____ Copies of Medical Records You Already Have
_____ Other (Please list below.)
Name of person completing this disability report: Joan Public
Mail or bring to:
SOCIAL SECURITY ADMINISTRATION
5 PARK CENTER CT
SUITE 100
OWINGS MILLS, MD 21117

Social Security Online

Adult Disability Report

ZZZVRFLDOVHFXULW\JRY



Joan6,!!! !!$
Overview

Identification

Printing Instructions

Submit

Medical
Receipt

Work/Education

Remarks

Review

Submit

Next Steps

<< [P]revious


Submit


6XEPLW5HSRUW
0  -",--'"--( -
 
-2
1(- ,
--  -"
-'-.(A-131(- -
1( (
(
 -(
,03257$1701&, ,-, )--'"-((
-""
-'
,-,--(
2
1 (-- )' (*"
-",--(*-'((+" ,-:-. (
(- --'
 
-


2
  -",--'"-."-'
,-,--(
[S]ign Off (finish later)

<< [P]revious

Submit



Social Security Online

Adult Disability Report

ZZZVRFLDOVHFXULW\JRY

6LJQ2IIILQLVKODWHU
6(-" -'" *
"-2
'"-" -'" *." - "

 ((- " ,) )2(

6(--'" *

7R&RPH%DFNWR7KLV5HSRUW/DWHU
@--'"1,"-;'--##111" "-*# -" ,--;
%
-;@ )-:-2 
- -;
$&(
 
-, (:(-,

1RW&RPLQJ%DFN"
2
(- (---'"-((.,-1 (-- 
" ,-
,(
-"
"-" (-:(-, (
%7(- -
 
-- ) ( (-(-6 "--'"- --'"
" ,--((
File Typeapplication/pdfFile TitleApply Online for Disability BenefitsAuthor290101File Modified2010-12-08File Created2010-10-08