Disability Screening Form I am * Interested in Disability Benefits for Myself Referring a family member or friend A provider referring a patient A Health plan referring a patient/member A Hospital employee referring a patient Other Is the disabled individual currently working? * Yes No Disabled Individual’s Name: * First Name Last Name Disabled Individual’s Email Disabled Individual’s Phone Number (###) ### #### Referring Individual's Name First Name Last Name Referring Individual's Email Referring Individual's Phone (###) ### #### Referring Individual's Title/Relationship to Disabled Comments Thank you!
