Disability Report - Adult, (Internet Version)

iClaim-i3368 Marriage (1^st Party): Screen Package 0.5

Table of Contents

1. Ent002_Welcome Page (DIB) Error! Bookmark not defined.

2. Ent003_Welcome Page (RIB) Error! Bookmark not defined.

3. Ent003_Welcome Page (RIB) Secure Session Error! Bookmark not defined.

4. Who is Completing This Application? (DIB or RIB Path) Error! Bookmark not defined.

5. Who is Completing This Application? (RIB Path with Secure Session) Error! Bookmark not defined.

6. Ent004_Return to Saved Application Process Error! Bookmark not defined.

7. Ini002-d1_Information About You (DIB or RIB path with no navigation) Error! Bookmark not defined.

8. Ini002-d1_Information About You (Secure Session RIB Path with no navigation) Error! Bookmark not defined.

9. Ini002-d1_Information About You (DIB with navigation) Error! Bookmark not defined.

10. Ini002-d1_Information About You (RIB with navigation) Error! Bookmark not defined.

11. Ini003-1_Contact Information Error! Bookmark not defined.

12. Ini003-1_Birth and Citizenship Information Error! Bookmark not defined.

13. Apn001-d1_Re-entry Number Error! Bookmark not defined.

14. Apn001-d1_Re-entry Number (SSI Definition link expanded) Error! Bookmark not defined.

15. Adi001-1_Other SSNs and Names Error! Bookmark not defined.

16. Fam001-1_Marriage information Error! Bookmark not defined.

17. Fam002-1_Prior Marriages Error! Bookmark not defined.

18. Fam003-d1_Children Error! Bookmark not defined.

19. Mil001-1_Military details Error! Bookmark not defined.

20. Ear001-1_Employer Details Error! Bookmark not defined.

21. Ear002-1_Self-Employment Error! Bookmark not defined.

22. Ear003-1_Supplemental Information Error! Bookmark not defined.

23. Ear004-d1-b_Total Earnings Error! Bookmark not defined.

24. Ear005-d1-b_Other Pensions/Annuities Error! Bookmark not defined.

25. Wst002-1_Direct Deposit Details Error! Bookmark not defined.

26. Bni001-1_Benefit Information Error! Bookmark not defined.

27. Bni002-1_Health Insurance (RIB or RIB/DIB Path only) Error! Bookmark not defined.

28. Bni005-1_Group Health Plan Insurance (RIB or RIB/DIB Path only) Error! Bookmark not defined.

29. Dsq001-1_Ability To Work Error! Bookmark not defined.

30. Dsq002-1_Disability Payments Error! Bookmark not defined.

31. Dsq003-1_Dependents Error! Bookmark not defined.

32. Dsq004-1_Authorization Error! Bookmark not defined.

33. Rem001_Remarks Error! Bookmark not defined.

34. Ovs001-d1-b_Review and Sign (iClaim) Error! Bookmark not defined.

35. Pin001-1_Contact Information 3

36. Pin001-1_Contact Information (i3368 only) 5

37. Confirm Your Identity On Re-entry (1^st party to 1^st party) 7

38. Re-entry Number (i3368 only) 8

39. Alg001-1_Conditions 9

40. Con001-1_Someone Who Knows About Your Condition 11

41. Doc001-1_Doctors and healthcare professionals 13

42. Doc002-1_Doctors and healthcare professionals details 14

43. Hos001-1_Hospitals and Clinics 17

44. Hos002-1_Hospital and Clinic Details 18

45. Tst001-1_Medical tests 22

46. Tst002-1_Medical Test Details 23

47. Med001-1_Medicines 25

48. Med002-1_Medicine Details 26

49. Msc001-1_Other medical records 28

50. Msc002-1_Other Medical Record Details 29

52. Win001-1_Work Status 31

53. Wac001-1-sw_Work Activity 32

54. Wac001-1-cw_Work Activity 33

55. Wac001-1-nw_Work Activity 34

56. Job001-1-sw_Job History 35

57. Job001-1-cw_Job History 38

58. Job001-1-nw_Job History 41

59. Edu001-1_Education and Training 42

60. Rmk001-1_Remarks 43

61. Rvw001-1_Review (i3368) 44

62. Mrf003-1_Medical Release Form Error! Bookmark not defined.

63. Wtn001-d1_Confirmation (With electronic Signature) Error! Bookmark not defined.

Note: Electronically signed medical release form will be displayed in html format similar to the current system. Error! Bookmark not defined.

64. Wtn001-d1_Confirmation (Without electronic Signature) Error! Bookmark not defined.

65. Cov001-1_Cover Sheet Pop-up Error! Bookmark not defined.

66. Rec001-1_Receipt Pop-up Error! Bookmark not defined.

35. Pin001-1_Contact Information

35. Pin001-1_Contact Information (i3368 only)

35. Confirm Your Identity On Re-entry (1^st party to 1^st party)

35. Re-entry Number (i3368 only)

35. Alg001-1_Conditions

35. Con001-1_Someone Who Knows About Your Condition

35. Doc001-1_Doctors and healthcare professionals

35. Doc002-1_Doctors and healthcare professionals details

35. Hos001-1_Hospitals and Clinics

35. Hos002-1_Hospital and Clinic Details

35. Tst001-1_Medical tests

35. Tst002-1_Medical Test Details

Note: When user selects “Other Medical Professional” in the dropdown for “Who sent you…”, the buttons “Add Doctor/Healthcare Professional” and “Add Hospital/Clinic” are displayed on the screen. It is mandatory for the user to select either of the buttons in order to continue.

When user selects either of the buttons, he is taken to Doctor or Hospital details page. Any action on the Doctor or Hospital details page should navigate them to the Tests page (Tst001-1_Medical tests)

35. Med001-1_Medicines

35. Med002-1_Medicine Details

Note: When user selects “Other Medical Professional” in the dropdown for “Who recommended…”, the buttons “Add Doctor/Healthcare Professional” and “Add Hospital/Clinic” are displayed on the screen. It is mandatory for the user to select either of the buttons in order to continue.

When user selects either of the buttons, he is taken to Doctor or Hospital details page. Any action on the Doctor or Hospital details page should navigate them to the Medicines page (Med001-1_Medicines)

35. Msc001-1_Other medical records

35. Msc002-1_Other Medical Record Details

36. Win001-1_Work Status

35. Wac001-1-sw_Work Activity

35. Wac001-1-cw_Work Activity

35. Wac001-1-nw_Work Activity

35. Job001-1-sw_Job History

35. Job001-1-cw_Job History

35. Job001-1-nw_Job History

35. Edu001-1_Education and Training

35. Rmk001-1_Remarks

35. Rvw001-1_Review (i3368)

i Claim-i3368 Marriage (1^st Party): Screen Package 0.5

January 25, 2021 Page 4 of 26