Social Security Intake

Social Security Representative Client Intake
Full Legal Name
Have you used any other names?
Social Security Number SSN
Mailing Address
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Marital Status
If Married Name of Spouse
Do you have insurance? If so the name of carrier?
Are you looking to get Medicare Part B & D? ( Outpatient and prescription?)
Do you have any children?
Email Address
example@example.com
Are you a US Citizen?
Place of Birth (City and State)
Diagnoses
Primary Care Provider
Other Providers names addresses
Current Medications
Medical Summary
Hospitalizations Dates Facilities

MonthDayYear
Date
EMPLOYMENT HISTORY (Last 15 years)
List all employers, job position, approximate start and end date, and wages earned at each job.
4 Education and Training
Highest Grade Completed
Physical Limitations
Impact on Daily Activities
MentalEmotional Limitations
VA Benefits
6 Other Benefits
Workers Compensation
Other Public Assistance
Private Disability Insurance
Estimated annual income for 2025*
Estimated annual income for 2026*
I authorize my representative to access and use my personal, financial, and medical records to assist in my claim to Social Security Administration.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty: