Midwest Disability PA - Disability Inquiry Form

1-800-473-6314

Social Security Disability Form

Date:

How did you hear about us?:

Name:

DOB:

Address:

Phone:

Current SSA Level:

Last Day Worked:

Have you collected unemployment or been in jail since you last worked?:

Disabilities:

CD issues:

Surgery:

Medications:

Treating physicians:

Doctors that support the client as disabled:

Education:

Employment History:

Emergency contact name & number:

Any children under the age of 18:

Physical limitations:

408 Northdale Blvd.,
Minneapolis, MN 55448

1-800-473-6314

Phone: 763-422-3770
Fax: 763-862-7521