Forms When Applying For Social Security Disability Insurance SSDI

Forms When Applying For Social Security Disability Insurance SSDI




Health References

When you are chronically ill it can be beyond difficult to gather information for your Social Security Disability Insurance application. Hopefully, this HypoGal post will make it a little more easier.

A sufficient long-term illness can wipe you out financially.

Applying for Social Security Disability Insurance may help your insure your financial well-being.

Here are some helpful tips to help get you organized before you apply for Social Security Disability Insurance S.S.D.I.

  • Note the date when your first became ill
  • Keep a timeline of all your doctor appointments and hospital stays
  • Have a list that contains your doctor or doctors information

Your doctor’s information should include the doctor’s name, address, phone number and your doctor’s speciality eg. Endocrinologist.

You need to be organized and detailed. It is important that you keep all information from your illness together. A three ring binder with divider tabs may help you with the organization of your records.

I realize you make feel deathly ill, unable to move, to dizzy to sit up but unless you complete the Social Security Disability Insurance forms you most likely will never receive any SSDI benefits. If you have a friend or family member that can help you then please ask for their help.

If you have neighbors or friends that are familiar with your disability struggles then you should ask them to complete a form that looks similar to this form:

(Please note the following forms should be printed from a desktop view)



Statement From Friends and Family

Your Name (Friend or Family Member)

Date: ____________________________________________________________________
Month                Day                    Year

Street Address

City                                State                         Zip Code

I have known_______________________________________________________________
The Person Who Is Submitting This Form

Period of Time

(3) I know __________________________________________________________________
Person Who is Submitting This Form

from ______________________________________________________________________
Family/ Friend/ Neighbor/ Work/ School/ Church

I have noticed the following changes in their personality and/or physical appearance from the time of

___________, 20_____________   to  ___________, 20_______________


Statement From Family and Friends



(5) Some of the changes in their personality and/or physical appearance:


Name Printed ________________________________________________________________

Signature ___________________________________________________________________

Dated ______________________________________________________________________
Month                     Day                     Year


Phone Number _______________________________________________________________


Street Address ________________________________________________________________

City                                               State                                  Zip Code

If the person has numerous remarks about your personality and/ or physical appearance you may want them to write, “See Attachment” in area (5) and attach a separate page labeled #5 that details your changes.

The letter should be concise, give examples and dates.

If a close neighbor has noticed that you have been too sick to mow your lawn or tend to your garden over a certain time period then they should include this in the area 5 Remark section. An example may read as the following:

My neighbor (Your Name) use to mow their lawn and tend to his garden every weekend. However, since the start of this summer I have noticed ( Your Name) has not had the strength to keep up with his lawn maintenance.

If a family member has helped you with errands, chores and is aware that you are too sick to maintain your job, then your example may want to read like this:

My sister, (Your Name) use to do her family’s laundry, grocery shop, run two miles every morning and work forty hours a week. Over the past year I have watched my sister’s health decline. Her husband now does all the laundry, I help with the family grocery shopping and errands. Our mother watches her twin seven year olds girls after school. My sister has had to give up job she loved and she spends her day in bed or on the couch. She is too weak to sit up and she usually only showers twice a week with my help.

The Statement of Attending Physician is Below

Your doctor may charge you a small fee to complete this form. Even if your doctor charges you a fee it is a good idea to have this form or a form similar to this form completed.

A judge and/ or the insurance company will be better equipped to approve your application if a complete summary of your medical condition is conveyed by your doctor.

If you have your doctor complete this Physician Statement Form it will assist a judge or insurance company representative in evaluating your medical condition.

A judge or insurance representative may not be able to fully interpret the complexity of your medical records. A summary of your medical condition will give a judge or insurance representative a concise overview from a medical expert.



Statement Of Attending Physician

Patient: ______________________________________________________________________

Date of Birth: ________________________________________________________________
Month            Day             Year

Present Condition: ____________________________________________________________

Subjective Symptoms:

Objective Findings:

(2) Please list ICD9 #


(3.1) Date of First Visit Mo._______ Day _______ 20________

(3.2) Date of Last Visit Mo.________ Day________ 20________

(3.3) Frequency of Visits:  Weekly     Monthly    Other

(3.4) Progress:  Recovered   Improved   Unimproved

Extent of Disability

(4.1) For Any Occupation?  Yes  No

(4.2) For His/Her Regular Occupation?  Yes  No

(4.3) Is patient now totally disabled?  Yes  No

(4.4) Does the disability or impairment prevent the patient from standing for six to eight hours? Yes  No

(4.5) If the patient can stand at all, and if so for how long?

(4.6) Does the disability or impairment prevent the patient from sitting upright for six to eight hours?  Yes  No

(4.7) If the patient can sit at all, and if so for how long?

(4.8) If the patient cannot stand and/or sit upright for six to eight hours, what is the reason?

(4.9) Does the disability or impairment require the patient to lie down during the day? Yes  No

(4.10) If the answer is yes then please explain why?

(4.11) How far can the patient walk non stop?:

(4.12) How much weight can the patient lift and carry during an eight hour period?

Less than 5 lb.    5- 10 lb.     11-20 lb.      21-50 lb.       Over 50 lb.

Please check the frequency with which the patient can perform the following activities:

Percentage of Time  nbsp;nbsp;              Rarely 0- 29%        Frequently 30-70%        Consistently 71-100%

Reach Up Above Shoulders

Reach Down to Waist Level

Down Towards Floor

Carefully Handle Objects

Able to Squat

Able to Kneel

(4.14) When do you think the patient will be able to resume any type of work?

Approximate Date:

Month __________ Day________ 20_______  Indefinitely  Never

Does the patient have any complaints of pain?  Yes  No

(5.1) If the patient has pain, what is the nature of the pain?

(5.2) How frequent is the pain?  Continuous  Hourly  Daily  Weekly

(5.3) How would you describe the level of pain?  Mild  Moderate  Severe

Is the patient a suitable candidate for a rehabilitation program?  Yes  No

(7) Mental Condition:

(8) Is the patient competent to endorse checks and direct the use of the proceeds thereof?

Yes         No

(9) Remarks:




Date ____________________________________________________

Name of Physician (Please Print)___________________________________________________

Signature_________________________________________________ Degree _____________

Street Address

City                        State                   Zip Code


Physician’s Stamp

What You Need To Remember When Applying For Social Security Disability Insurance

If you apply for disability in person, remember you have requested disability benefits because you are too sick or injured to work.

You need to be completely honest about your condition. To qualify for disability benefits under Social Security you must be totally disabled. Benefits are not given for a short-term disability or partial disability.

Every person that files a Social Security Disability Application is responsible for showing medical evidence that validates the severity of the impairment.

You should have all of your medical information available before you apply for Social Security Disability Insurance.

An approximate 70% of all SSDI applications are denied the first time.

You will most likely become part of the 70% statistic if your SSDI application is not completed correctly.

The Statement of Attending Physician form and the Statement From Friends and Family form provided on this HypoGal Blog may help you expedite your Social Security Disability Application.

You are far more likely to have your SSDI application approved the first time if you have a completed and detailed application.

Please remember, your financial well being may rely on this one application.


I hope this HypoGal post Forms When Applying For Social Security Disability Insurance SSDI has been useful.

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