Intake Action Sheet

Name: ________________________
Date: __________________

[ ] Letter to Local Office:

[ ] New Application Letter

[ ] Cover Letter (in a pending case) With:

[ ] Request for Reconsideration

[ ] Request for Hearing

[ ] Disability Report—Appeal

[ ] Signed Releases

[ ] Appointment of Representative Form

[ ] Attorney or Client Fee Agreement

[ ] Direct Payment of Authorized Fees Form SSA-1695

[ ] cc to Office of Disability Adjudication and Review

[ ] cc to Client With Fee Agreement

[ ] cc to Disability Determination Bureau With Enclosures

[ ] Re-Open Prior Application

[ ] Request Local Hearing

[ ] Appealing Onset Date Only

[ ] Opening Letter to Client

[ ] Thank You Letter to Referral Source

[ ] Letter to Client With Diary:

[ ] Seizure Diary

[ ] Headache Diary

[ ] MS Diary

[ ] Other: ____________________

[ ] Letter to Disability Determination Bureau:   Now   Send in 30 Days

[ ] Request Medical CE

[ ] Request Psych CE

[ ] Request State Agency RFCs (both physical and mental)

[ ] Request State Agency “Electronic Worksheet” and/or Rationale for Denying Claim

[ ] Supply Additional Medical Records

a.

b.

c.

[ ] Supply Photos

[ ] Other: __________________

[ ] Letter to Local Office Requesting eDib File (CD)

[ ] Letter to Office of Disability Adjudication and Review

[ ] Request DISCO DIB Earnings Record

[ ] National Directory New Hire, Wage and Unemployment Report for the Following Years: __________________________

[ ] Detailed Earning Report: _____________ to Present

[ ] Other:

[ ] Letter to Former Employer (__________________) Requesting Confirmation of Last Day of Work

[ ] Letter to Former Employer Requesting Personnel File (specify portion or specific documents)

[ ] Letter to Medical Providers Requesting Records:

a.  covering

b.  covering

c.  covering

d.  covering

[ ] Letter to Vocational Rehabilitation Agency Requesting Copy of File

[ ] Run Client Through Legal Database