Social Security Forms

Workers Compensation/Public Disability Questionnaire

SSA-546 Print and fill out by hand (67 kb)
SSA-546 Fill out online, then print (159 kb)

Disability Report-Adult

SSA-3368 Print and fill out by hand (125 kb)
SSA-3368 Fill out online, then print (426 kb)

Work History Report

SSA-3369 Print and fill out by hand (80 kb)
SSA-3369 Fill out online, then print (385 kb)

Hearing Request

Claimant's Statement when 'Request for Hearing' is filed and issue is Disability

HA-4486 Print and fill out by hand (101 kb)
HA-4486 Fill out online, then print (157 kb)

HEARING PREPARATION

Recent Medical Treatment

HA-4631 Print and fill out by hand (243 kb)
HA-4631 Fill out online, then print (259 kb)

Medication List

HA-4632 Print and fill out by hand (46 kb)
HA-4632 Fill out online, then print (65 kb)

Recent Work History

HA-4633 Print and fill out by hand (216kb)
HA-4633 Fill out online, then print (231 kb)

• Spinal Injuries

  Back and spinal cord injuries make even office work almost unbearable to endure. What may seem like a minor inconvenience one day may turn into an incapacitating injury the next.

• Mental Disorders

  Mental disorders and health issues can make going to work nearly impossible. You may be eligible to collect Social Security disability benefits or Supplemental Security Income (SSI) if you suffer from a disabling mental illness.

• Chronic Pain

  If you are suffering from an injury or illness that causes you such pain that you are unable to work, you may have a claim for Social Security disability benefits.

• Rheumatoid Arthritis

  Rheumatoid arthritis is an extremely painful and debilitating condition that can make everyday tasks nearly impossible to perform.

• Fibromyalgia

  Fibromyalgia Syndrome (FMS) is a serious condition that involves significant pain and near constant fatigue.

• Hepatitis C

  Severe cases of Hepatitis C can result in liver disease and can cause a variety of potentially debilitating symptoms that makes performing everyday tasks and work functions extremely difficult.

• Post-Traumatic Stress Disorder

  While most commonly associated with military personnel, post-traumatic stress disorder can impact people from all walks of life as a result of many different kinds of experiences.

• Headaches

  Chronic headache sufferers are dealing with a condition that can be debilitating to the point of an inability to function. When headaches are severe enough that you are unable to work, you may be able to collect Social Security Disability Insurance (SSDI) benefits.

• Chronic Fatigue

  Chronic Fatigue Syndrome (CFS) sufferers are physically and mentally exhausted the majority of the time. Other symptoms can include memory and concentration problems, joint and muscle pain, sore throat and pain in the lymph nodes.

• Multiple Sclerosis

  Multiple sclerosis is a disease that impacts the brain and spinal cord. In many cases, the effects of multiple sclerosis make it nearly impossible for victims to perform even the most basic tasks.

• Lupus

  Lupus is a condition that is referred to as an autoimmune disease which causes your immune system to attack healthy tissues rather than damaged ones. There are times when the symptoms of lupus can be so debilitating that the victim is not able to work.

• Cancer

  Anyone who has ever been diagnosed with cancer, or knows someone who has, understands what an aggressive and debilitating disease it can be.

• Depression & Bipolar Disorder

  The feelings of hopelessness or pessimism that come with depression or the dramatic mood swings in people suffering from bipolar disorder can make it nearly impossible to stay focused long enough to complete even the most basic daily tasks.

• Lung Disease

  From asthma to chronic obstructive pulmonary disease (COPD), lung disease has the potential to leave its victims unable to function normally or perform basic job related tasks.

• Coronary Disease

  People dealing with coronary conditions like congestive heart failure and artery diseases can have a very hard time accomplishing even the most basic tasks on a daily basis.

• Diabetes

  Diabetes is a serious condition that affects millions of Americans. The condition can lead to serious nerve damage, vision problems and kidney failure that can make it nearly impossible to function normally.