Hello! Thanks for visiting our benefits pre-screening web page. This is a secure site. Your information will not be shared or sold and we will use this information for the sole purpose of determining eligibility for the program. Your participation is voluntary and will not affect your benefits as a health plan member. The appropriate government agency will make the final eligibility determination.

This screening is confidential and free to you.

The questions are simple, and this should only take a few minutes.

How did you hear about us?
Relative
Friend
Publication
Other
I am completing this form for:
Name of who needs to file for Social Security Disability Benefits:

















Please also provide your E-mail address:
Are you currently working?
No
Are you currently receiving SSI (Supplemental Security Income) for a disabling condition?
No
Are you currently receiving SSD (Social Security Disability)?
No
Have you applied for SSI/SSD?
No
Are you currently being represented by an attorney?
No
Please provide any medical conditions that currently prevent you or this person from working, completing daily tasks or performing in school (if a child):


Thank you very much! Now just click on the "Done" button...