Assessment | Advanced Patient Advocacy

Do you wonder if you qualify for Social Security Disability benefits?
Have you worked 5 of the last 10 years, are between the ages of 21 and 65 years old and currently out of work?
Complete this FREE screening to have an experienced advocate review your case.

What medical condition(s) are keeping you from working (both physical and mental limitations)?

Date of Birth (mm/dd/yyyy):

Gender:

male female

What is your marital status?

How many minor dependents do you support?

Which of the following daily activities are you able to complete yourself (check all that apply)?

cooking
light house work
light yard work
dress myself
pay my own bills
shopping for groceries

Would you like an Advocate to contact you to discuss how Advanced Patient Advocacy can help you with your disability claim?

yes no

First Name:
Last Name:
Address:
City:
State:
Zipcode:
E-mail Address:
Telephone:

Best time to contact

morning afternoon evening

Your screening information has been received. Our Advocates work Monday through Fridays (8am until 5pm). You will be contacted on the next business day with information about your screening and how we can help you secure the Social Security Benefits you have earned. You may also contact us directly at (877) 676-7650 Easter Standard Time or via email at: Disability@apallc.com