Form SSAKIT iviv i Benets i iviv i ii iiiiiiiii i vii iiiiiiiiv i iviiiiiiv ii - PDF document

SSA-1170-KIT That Vou Jhould 9now Before Vou Apply forJosial Jesurity )isaiility (over) That Vou Jhould 9now Before Vou Apply forJosial Jesurity )isaiility Benets e sent you this disaiility starter kit iesause you requested an appointment to le for disaiility ienets. Lhe enslosed letter has the date, time, and losation of your appointment.Lhe following are answers to questions most people ask aiout when applying for disaiility ienets. 9nowing the answers to these questions will help you understand the prosess.A Josial Jesurity representative will interview you and somplete an applisation for disaiility ienets and an Adult )isaiility Ieport. Lhe interview will take plase either in your losal Josial Jesurity ofse or iy telephone. 3t will take at least 1 hour.Vou san sut your interview time in half iy starting the prosess online. Vou san somplete online, B?L2 the and the iy going toywww.sosialsesurity.gov/applyfordisaiilityVou still need to with the losal Josial Jesurity ofse, so a representative san review your information.3f you sannot do iusiness with us online, you san somplete the enslosed Medisal and 8oi Torksheet and have it ready for your appointment.Vou san also speed things up iy iringing to your ofse appointment the information listed on the enslosed shesklist. 3f you have an appointment iy telephone, the representative may ask you to provide any required shesklist items.By law, Josial Jesurity has a very strist denition of disaiility. Lo ie found disailedy Vou must ie unaile to do any suistantial work iesause of your medisal sondition(s); Vour medisal sondition(s) must have lasted, or ie expested to last, at least 1 year, or ie expested to result in your death.No. Vou sannot get disaiility ienets solely iesause your dostor says you are disailed. That Vou Jhould 9now Before Vou Apply for Josial Jesurity )isaiility Benets No. Josial Jesurity disaiility laws are different from most other programs. 0or example, Josial Jesurity does not pay ienets for partial disaiility. 1enerally, it takes aiout 3 to 5 months to get a desision. 2owever, the exast time depends on how long it takes to get your medisal resords and any other evidense needed to makea desision. Te send your applisation to a state agensy that makes disaiility desisions. Lhe state has medisal and vosational experts who will sontast your dostors and other plases where you reseived treatment to get your medisal resords.Lhe state agensy may send you forms to somplete or ask you to have an examination or medisal test. 3f the state does request an examination, makeVou will not have to pay for any examination or test you are sent for, iy the state agensy. Josial Jesurity pays disaiility ienets under two programsy Josial Jesurity )isaiility 3nsuranse (JJ)3) for insured workers, their disailed surviving spouses, and shildren (disailed iefore age 22) of disailed, retired, or deseased workers. Jupplemental Jesurity 3nsome (JJ3) for people with little or no insome and resourses. s. Josial Jesurity protests the privasy of eash individual we serve. As a 0ederal agensy,we are required iy the Grivasy Ast of 1974 (5 N.J.C. 522a) to protest the information we get from you. Vou are ensouraged to iring a friend or relative to translate for you. Te provide free interpreter servises to help you sondust your Josial Jesurity iusiness. 2owever, we need advansed notise to make arrangements with the translator. Vou san visit our weisite at www.sosialsesurity.gov, ask the interviewer during your appointment, or sall us toll-free at 1-800-772-1213 (for the deaf or hard of hearing, sall LLV 1-800-325-0778). \r\f\n\t\r\f\r\f\n\t\b\r\b\b\b\r\b\b\b\r\b\r  \r\r\n\n\t\t\f  \r\f\b\r
\r  \b\b\b\b\r  \b\b\r   \b\r  ­€‚\b  \b\r  \b\b\r  ƒ\b„……†‚‡ˆ‰†Š ƒ\b……†\r\r  ƒ\b\r‹ŒŽ‘†’\n\t\r“­\b\b\r\b\t\r\r\f Form (12-2009) Destroy prior editionsMEDICAL AND JOB WORKSHEET - ADULT mail this worksheet to your local of�ce.Did you know that you can start the application process online? the application for Social Security disability bene�ts. You should bring this worksheet to your appointment or have it with you if your appointment is by telephone. List all of the physical or mental conditions (including emotional or learning problems) that limit your ability to work. If you have cancer, please include the stage and type. List each condition separately. CONDITIONS If you are not working, when did you stop working? Please list any doctors, hospitals, clinics, therapists, or emergency rooms you have visited because of your conditions. NAMEADDRESSPHONE NUMBER(with area code)DATE FIRST SEEN OR ADMISSION DATEDATE LAST SEEN OR DISCHARGE DATE Please list any medicines you take and why you take them. If prescribed, please provide the doctor’s name. NAME OF MEDICINEWHY YOU TAKE ITPRESCRIBED BY Please list any medical tests you had or are going to have in the future. NAME OF TESTPROVIDER WHO SENT YOUDATE(S) List the jobs (up to 5) that you have had in the 15 years before you became unable to work because of your physical or mental conditions. List your most recent job �rst. JOB TITLEe.g., cookTYPE OF BUSINESSe.g., restaurantDATES WORKED FROMMo/YTOMo/YrHOURS PER DAYDAYSPER WEEKRATE OF PAYAmountFrequency Form (12-2009) Destroy prior editions We will help you get any missing information.telephone. Do not delay �ling your application, even if you do not have all of the information. Bring this worksheet to your appointment or have it with you if your appointment is by