Disability Report - Adult, (Internet Version)

iClaim-i3368 Marriage (3rd Party): Screen Package 0.2

Table of Contents

1. Ent002_Welcome Page (DIB) 3

2. Ent001_Welcome Page (RIB) 4

3. Ent001_Welcome Page (RIB) Secure Session 5

4. Who is Completing This Application? (DIB Path) 6

5. Who is Completing This Application? (RIB Path) 8

6. Ent004_Return to Saved Application Process 10

7. Ini002-d3_Information About You (DIB with no navigation) 11

8. Ini002-d3_Information About You (RIB with no navigation) 12

9. Ini002-d3_Information About You (DIB with navigation) 13

10. Ini002-r3_Information About You (RIB with navigation) 14

11. Ini001-d3 & r3_Preparer’s Contact Information (DIB & RIB Paths) 15

12. Ini003-3_Contact Information 16

13. Ini003-3_Birth and Citizenship Information 18

14. Apn001-d3_Re-entry Number 19

15. Apn001-d3_Re-entry Number (SSI Definition link expanded) 20

16. Adi001-3_Other SSNs and Names 21

17. Fam001-3_Marriage Information 23

18. Fam002-3_Prior Marriages 24

19. Fam003-d3_Children 25

20. Mil001-3_Military Details 26

21. Ear001-3_Employer Details 27

22. Ear002-3_Self-Employment 29

23. Ear003-3_Supplemental Information 30

24. Ear004-d3-b_Total Earnings 31

25. Ear005-d3-b_Other Pensions/Annuities 32

26. Wst002-3_Direct Deposit Details 33

27. Bni001-3_Benefit Information 35

28. Bni002-3_Health Insurance 37

29. Bni005-3_Group Health Plan Insurance 38

30. Dsq001-3_Ability To Work 38

31. Dsq002-3_Disability Payments 40

32. Dsq003-3_Dependents 41

33. Dsq004-3_Authorization 42

34. Rem001_Remarks 43

35. Ovs001-d3-b_Review and Sign (iClaim) 44

36. Rcm001-3_Preparer’s Contact Information 48

37. Rcm001-3_Preparer’s Contact Information (i3368 only) 49

38. Pin001-3_Contact Information 50

39. Pin001-3_Contact Information (i3368 only) 52

40. Re-entry Number 54

41. Re-entry Number (i3368 only) 55

42. Confirm Your Identity On Re-entry (1st party to 3rd party) 56

43. Confirm Your Identity On Re-entry (3rd party to a different 3rd party) 57

44. Alg001-3_Conditions 58

45. Con001-3_Someone Who Knows About Your Condition 60

46. Doc001-3_Doctors and Healthcare Professionals 62

47. Doc002-3_Doctors and Healthcare Professionals Details 63

48. Hos001-3_Hospitals and Clinics 66

49. Hos002-3_Hospitals and Clinics Details 67

50. Tst001-3_Medical Tests 71

51. Tst002-3_Medical Test Details 72

52. Med001-3_Medicines 74

53. Med002-3_Medicine Details 75

54. Msc001-3_Other Medical Records 77

55. Msc002-3_Other Medical Record Details 78

57. Win001-3_Work Status 80

58. Wac001-3-sw_Work Activity 81

59. Wac001-3-cw_Work Activity 82

60. Wac001-3-nw_Work Activity 83

61. Job001-3-sw_Job History 84

62. Job 001-3-cw_Job History 87

63. Job 001-3-nw_Job History 90

64. Edu001-3_Education and Training 91

65. Rmk001-3_Remarks 92

66. Rvw001-3_Review (i3368) 93

67. Mrf003-3_Medical Release Form 98

68. Wtn001-d3_Confirmation 99

69. Cov001-3_Cover Sheet pop-up 100

70. Rec001-3_Receipt Pop-up 101

36. Rcm001-3_Preparer’s Contact Information

36. Rcm001-3_Preparer’s Contact Information (i3368 only)

36. Pin001-3_Contact Information

36. Pin001-3_Contact Information (i3368 only)

36. Re-entry Number

36. Re-entry Number (i3368 only)

36. Confirm Your Identity On Re-entry (1st party to 3rd party)

36. Confirm Your Identity On Re-entry (3rd party to a different 3rd party)

36. Alg001-3_Conditions

36. Con001-3_Someone Who Knows About Your Condition

36. Doc001-3_Doctors and Healthcare Professionals

36. Doc002-3_Doctors and Healthcare Professionals Details

36. Hos001-3_Hospitals and Clinics

36. Hos002-3_Hospitals and Clinics Details

36. Tst001-3_Medical Tests

36. Tst002-3_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 (Tst001-3_Medical tests)

36. Med001-3_Medicines

36. Med002-3_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 (Med001-3_Medicines)

36. Msc001-3_Other Medical Records

36. Msc002-3_Other Medical Record Details

37. Win001-3_Work Status

36. Wac001-3-sw_Work Activity

36. Wac001-3-cw_Work Activity

36. Wac001-3-nw_Work Activity

36. Job001-3-sw_Job History

36. Job 001-3-cw_Job History

36. Job 001-3-nw_Job History

36. Edu001-3_Education and Training

36. Rmk001-3_Remarks

36. Rvw001-3_Review (i3368)

i Claim-i3368 Marriage (3rd Party): Screen Package 0.2

January 25, 2021 Page 4 of 26