Empower Representation — Free Phone Consultation Request
Empower Representation will get back to you within 24 hours to arrange your free phone consultation. Free phone consultation, approximately 45–60 minutes. Submitting this request does not confirm an appointment or establish representation. Representation requires case review and board approval. Please do not include Social Security numbers, diagnoses, medical records, or detailed medical information. Empower will contact you to confirm a time. If you have an SSA deadline, do not wait for a response to protect your deadline.
Full Name
*
First Name
Last Name
Email Address
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current stage of your SSA claim
*
Please Select
Not yet filed
Initial Application
Reconsideration
Hearing Scheduled
Appeals Council
Other
Briefly describe your non-medical reason for inquiry
*
Is there an urgent appeal or hearing deadline?
*
Yes
No
Deadline date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SMS consent
By checking this box, I agree to receive SMS text messages from Empower Representation, Inc. at the phone number I provided about appointment reminders, status updates, and answers to frequently asked questions. Consent is optional and is not a condition of receiving services. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for assistance.
Scheduling member email
example@example.com
Consultation member email
example@example.com
Consultation appointment date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Consultation appointment time
Hour Minutes
AM
PM
AM/PM Option
Consultation appointment time zone
Consultation duration
Consultation scheduling status
Unscheduled
Scheduled
Rescheduled
Completed
Cancelled
Confirmed appointment details
Submit Free Phone Consultation Request
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