Intake Action Checklist 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 RFC (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