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Social Security Disability Contact Form

If your application for Social Security Disability benefits has been denied, you have the right to appeal. An attorney can assist you in the appeals process. To find out how our firm can help, contact us to schedule a consultation and case evaluation with a Social Security Disability attorney.

Helping You Understand Your Disability Benefits Options

The federal government has a number of disability benefit programs — generally grouped under Social Security disability (SSD) insurance and Supplemental Security Income (SSI) — for certain people who are unable to work full-time due to their disabilities.

At The Law Offices of Kenneth Hiller, PLLC, our attorneys help clients in Buffalo, Rochester, and Syracuse, and throughout western, central and upstate New York apply for disability benefits.

Below is some general information about the disability benefits that are available through the Social Security system. To discuss whether you are eligible for any benefit programs, contact us for a free consultation with an experienced lawyer.

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Social Security Disability Contact Form

Personal Information

Full name

Maiden name

Other names used

E-mail address

Phone number

Business phone

Cell phone

Address

City

State

Zip

Please describe all of your injuries, illnesses, symptoms, and disabilities, whether physical, mental, or emotional.

How do your medical problems limit your daily activities?

Are you able to work?
Yes No

Are/were you self-employed?
Yes No

What is your age?

What is the last grade you completed in school?

Do you have a high school diploma or its equivalent?
Yes No

Do you attend a vocational school or college or program?
Yes No

If so, what did you study and did you earn any certifications or licenses?

Did you attend college?
Yes No

If so, what did you study and did you earn any degrees?

Please describe any graduate study or advanced or professional degrees.

Do you possess any vocational or professional licenses?

Approximately how long have you been in the workforce? (years)

Describe briefly the types of work you have performed.

If you are able to work, how many hours can you work per week?

Have you filed for disability benefits for the medical problem/s described above?
Yes No

Have you been turned down for benefit payments based on the medical problem/s described above?
Yes No

Have you appealed a Social Security decision that denied you benefits for the medical problem/s described above?
Yes No

Other information or concerns?

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