Social Security Disability Screening Form

transparent Please complete this free and secure social security disability screening form and one of our SSA certified disability representatives will contact you within 48 hours to discuss your claim.

All fields marked with * are required.

First Name *
Please enter your first name.

Last Name *
Please enter your last name.

Email Address *
Please enter a valid e-mail address.

Full Telephone Number including area code.

ZIP (5 digits)

State

Age of Applicant *

Are you currently receiving medical treatment? *
 Yes No

If yes, how long have you been in treatment?

Are you currently working? *
 Yes No

Are you currently collecting Social Security benefits? *
 Yes No

Date you last worked.

Tell us about your disability.

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Type the characters you see above in the box below:

*Your information will never be shared with any third party and will remain confidential. Please read DECO’s HIPPA compliant privacy policy.