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215-561-1010
203-853-4999
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Pennsylvania

Two Penn Center
1500 John F. Kennedy Boulevard; Suite 1020
Philadelphia, PA 19102

215-561-1010 (office)
215-762-0465 (fax)
215-779-6095 (cell)
Connecticut

50 Washington Street
4th floor, P.O. Box 844
Norwalk, CT 06856-0844

203-853-4999 (office)
203-853-9429 (fax)

Social Security Disability Contact Form

Please complete the Social Security Disability contact form below, and we will contact you to arrange a free initial consultation.

Social Security Disability Contact Form:

First Name
:
Last Name
:
E-mail
:
Phone
:
Are you presently out of work due to a medical condition(s)
:
Yes No
Have you applied for SSD or SSI
:
Yes No
If yes, what is the status of your application?
:
If you were denied, how long ago were you denied?
:
What is your age?
:
Are you presently working
:
Yes No
If no, when was the last time that you worked
:
What kind of work have you done in the last 15 years
:
What medical conditions have you been diagnosed with that impairs your ability to work?
:
Are you presently receiving medical treatment for the conditions that prevent you from working?
:
Yes No
If no, why not
:
If you answered yes to the last question, are you seeing medical specialists trained to treat you for the conditions that impair your ability to work? 
:
Yes No
In the space below provide whatever details you want me to be aware of with regard to your disabilityclaim
:
 
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