Case Review Disability Security Social | Dynamic Disability Solutions

For a free social security disability case review, complete this form. Do not include your social security number. An experienced former Social Security Disability Program Expert or Senior Disability Examiner reviews your information. If you are under 65, with a severe disabling medical condition that is expected to last at least 12 months, complete this form. YOU MAY BE ENTITLED TO EARLIER RETIREMENT BENEFITS. Taxpayers pay for these benefits with Social Security payroll deductions - these are your benefits. THIS CASE REVIEW DOES NOT CONSTITUTE AN AGREEMENT TO REPRESENT YOU. REPRESENTATION REQUIRES A WRITTEN SIGNED AGREEMENT AND OTHER SSA FORMS. NO FEE UNLESS WE WIN, excludes costs.

Your Name
E-mail Address
City and State
Home Number	eg. (555) 555-5555
Mobile Number	eg. (555) 555-5555
Case Review Information
Describe Your Medical Condition(s) and How that Condition(s) Prevents You from Working
Date of Birth (for example, 11/05/1970)	/ / Date of Birth MM/DD/YYYY
Usual Occupation or Job
Highest Grade Completed in School
If You're Over 31, Have You Worked 5 Out of the Last 10 Years?	Yes No
Are You Working Now?	Yes No
Date You Stopped Working	MM/DD/YYYY
Do You Need Assistance with Application?	Yes No
Date of Your Most Recent SSA Denial Notice	MM/DD/YYYY
Do You Need Assistance with Disability Appeal?	Yes No
Do You Need An Experienced Advocate?	Yes No
Are You Regularly Seeing a Doctor?	Yes No
Has Your Doctor Limited Work Activities?	Yes No
Are You Receiving Other Disability Benefits?	Yes No
Are You a Veteran or Government Employee?	Yes No
Other Comments: