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pdfiClaim-i3368 Marriage (1st Party): Screen Package 0.5
Table of Contents
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1.
Confirm Your Identity On Re-entry (1 party to 1 party) ........................................................................................................... 2
2.
Re-entry Number (i3368 only) ........................................................................................................................................................ 3
3.
Alg001-1_Conditions ...................................................................................................................................................................... 4
4.
Con001-1_Someone Who Knows About Your Condition ............................................................................................................ 6
5.
Doc001-1_Doctors and healthcare professionals ........................................................................................................................ 8
6.
Doc002-1_Doctors and healthcare professionals details............................................................................................................ 9
7.
Hos001-1_Hospitals and Clinics .................................................................................................................................................. 12
8.
Hos002-1_Hospital and Clinic Details ......................................................................................................................................... 13
9.
Tst001-1_Medical tests ................................................................................................................................................................. 17
10.
Tst002-1_Medical Test Details ..................................................................................................................................................... 18
11.
Med001-1_Medicines .................................................................................................................................................................... 20
12.
Med002-1_Medicine Details ......................................................................................................................................................... 21
13.
Msc001-1_Other medical records ................................................................................................................................................ 23
14.
Msc002-1_Other Medical Record Details .................................................................................................................................... 24
16.
Win001-1_Work Status ................................................................................................................................................................. 26
17.
Wac001-1-sw_Work Activity ........................................................................................................................................................ 27
18.
Wac001-1-cw_Work Activity ........................................................................................................................................................ 28
19.
Wac001-1-nw_Work Activity ........................................................................................................................................................ 29
20.
Job001-1-sw_Job History............................................................................................................................................................. 30
21.
Job001-1-cw_Job History............................................................................................................................................................. 32
22.
Job001-1-nw_Job History ............................................................................................................................................................ 35
23.
Edu001-1_Education and Training .............................................................................................................................................. 36
24.
Rmk001-1_Remarks ...................................................................................................................................................................... 37
25.
Rvw001-1_Review (i3368)............................................................................................................................................................. 38
26.
Mrf003-1_Medical Release Form.................................................................................................................................................. 41
27.
Wtn001-d1_Confirmation (With electronic Signature) ............................................................................................................... 42
Note: Electronically signed medical release form will be displayed in html format similar to the current system. ...................... 42
28.
Wtn001-d1_Confirmation (Without electronic Signature) ......................................................................................................... 43
29.
Cov001-1_Cover Sheet Pop-up .................................................................................................................................................... 44
30.
Rec001-1_Receipt Pop-up ............................................................................................................................................................ 45
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iClaim-i3368 Marriage (1 Party): Screen Package 0.5
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1. Confirm Your Identity On Re-entry (1st party to 1st party)
XXXX
Insert Penalty Warning: Anyone who makes or causes to be made a false statement or
representation of material fact for use in determining a payment under the Social Security Act,
or knowingly conceals or fails to disclose an event with an intent to affect an initial or continued
right to payment, commits a crime punishable under Federal law by fine, imprisonment, or both,
and may be subject to administrative sanctions.
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2. Re-entry Number (i3368 only)
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3. Alg001-1_Conditions
xxxxxx
xxxxxxx
remove language
"that limit your
ability to work"
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4. Con001-1_Someone Who Knows About Your Condition
xx
xxx
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5. Doc001-1_Doctors and healthcare professionals
XXXXXX
XXXXXX
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6. Doc002-1_Doctors and healthcare professionals details
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7. Hos001-1_Hospitals and Clinics
xxxxxxx
xxxxxxx
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8. Hos002-1_Hospital and Clinic Details
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9. Tst001-1_Medical tests
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10.Tst002-1_Medical Test Details
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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)
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11.Med001-1_Medicines
X
XXXX
XXX
XXXXX
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12.Med002-1_Medicine Details
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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)
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13.Msc001-1_Other medical records
XXXXXX
XXXXXX
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14.Msc002-1_Other Medical Record Details
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16.Win001-1_Work Status
XXXXXXX
XXXXXXX
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17.Wac001-1-sw_Work Activity
XXXXXX
XXXXXX
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18.Wac001-1-cw_Work Activity
XXXXXXXX
XXXXXXXX
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19.Wac001-1-nw_Work Activity
XXXXXX
XXXXXXX
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20.Job001-1-sw_Job History
XXX
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21.Job001-1-cw_Job History
XXXXXX
XXXXXXX
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22.Job001-1-nw_Job History
XXXXXXXXXX
XXXXXXXXXXX
XX
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23.Edu001-1_Education and Training
XXX
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24.Rmk001-1_Remarks
XXXXXXXX
XXXXXXXX
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25.Rvw001-1_Review (i3368)
XXX
xxx
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Change to $1,090
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26.Mrf003-1_Medical Release Form
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27.Wtn001-d1_Confirmation (With electronic Signature)
Note: Electronically signed medical release form will be displayed in html format similar to the current system.
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28.Wtn001-d1_Confirmation (Without electronic Signature)
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29.Cov001-1_Cover Sheet Pop-up
XXX
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30.
Rec001-1_Receipt Pop-up
XXX
XX
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XXX
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Privacy Act Statement
Collection and Use of Personal Information
Section 205(a), 223(d), and 1631(e)(1) of the Social Security Act, as amended, allow us to
collect this information. We will use the information you provide to make a decision on the
named claimant’s claim. The Privacy Act (5 U.S.C. & 552a(b)) permits us to disclose the
information you provide on this form in accordance with approved routine uses. Giving us this
information is voluntary; however, failing to complete the required fields could prevent us from
processing your request. Additional information regarding this form, routine uses of
information, and other Social Security programs, is available on our internet website,
www.socialsecurity.gov, or at your local Social Security office.
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section
2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless
we display a valid Office of Management and Budget (OMB) control number. We estimate that
it will take about 90 minutes to read the instructions, gather the facts, and answer the questions.
Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401.
| File Type | application/pdf |
| Author | Fujitsu |
| File Modified | 2015-05-07 |
| File Created | 2015-05-07 |