Medical Developments

Name (as it appears on your Social Security card)*

First Last

Date of Birth*

Phone*

Benefits Received

Have you ever received Workers Compensation Benefits? (L&I, Labor andIndustries, etc.)*

Yes

No

If so, when?

L&I Contact Name

L&I Contact Phone

L&I Contact Fax/Email

L&I Contact Address

Street Address Address Line 2 City State ZIP Code

Have you ever received State Assistance (DSHS, ABD, TANF, GAU, etc)?*

Yes

No

If so, when?

Have you ever received FMLA, short-term, or long-term disability?*

Yes

No

If so, when?

FMLA, ST or LT Disability Contact Name

FMLA, ST or LT Disability Contact Phone

FMLA, ST or LT Disability Contact Fax/Email

FMLA, ST or LT Disability Contact Address

Street Address Address Line 2 City State ZIP Code

Have you ever received VA Benefits?*

Yes

No

If so, when?

Have you worked since the onset of your disability?*

Yes

No

If so, when?

Have you been incarcerated since the onset of your disability?*

Yes

No

If so, when?

Clinic Name*

Doctor Name*

Clinic or Doctor Address*

Street Address Address Line 2 City State ZIP Code

Doctor/Clinic Phone*

Medical Records Department Fax OR Email*

Are you still receiving treatment at this facility?*

Yes

No

Is this provider supportive of your claim for disability?*

Yes

No

I don't know

Do you have a second doctor or clinic to report?*

Yes

No

Clinic Name 2*

Doctor Name 2*

Clinic or Doctor Address 2*

Street Address Address Line 2 City State ZIP Code

Doctor/Clinic Phone 2*

Medical Records Department Fax OR Email 2*

Are you still receiving treatment at this facility? 2*

Yes

No

Is this provider supportive of your claim for disability? 2*

Yes

No

I don't know

Do you have a third doctor or clinic to report?*

Yes

No

Clinic Name 3

Doctor Name 3

Clinic or Doctor Address 3

Street Address Address Line 2 City State ZIP Code

Doctor/Clinic Phone 3*

Medical Records Department Fax OR Email 3*

Are you still receiving treatment at this facility? 3*

Yes

No

Is this provider supportive of your claim for disability? 3*

Yes

No

I don't know

Do you have a fourth doctor or clinic to report?*

Yes

No

Clinic Name 4*

Doctor Name 4*

Clinic or Doctor Address 4*

Street Address Address Line 2 City State ZIP Code

Doctor/Clinic Phone 4*

Medical Records Department Fax OR Email 4*

Are you still receiving treatment at this facility? 4*

Yes

No

Is this provider supportive of your claim for disability? 4*

Yes

No

I don't know

Do you have a fifth doctor/clinic to report?*

Yes

No

Clinic Name 5*

Doctor Name 5*

Clinic Address 5*

Street Address Address Line 2 City State ZIP Code

Doctor/Clinic Phone 5*

Medical Records Department Fax OR Email 5*

Are you still receiving treatment at this facility? 5*

Yes

No

Is this provider supportive of your claim for disability? 5*

Yes

No

I don't know

Do you have a sixth doctor/clinic to report?*

Yes

No

Clinic Name 6*

Doctor Name 6*

Clinic Address 6*

Street Address Address Line 2 City State ZIP Code

Doctor/Clinic Phone 6*

Medical Records Department Fax OR Email 6*

Are you still receiving treatment at this facility? 6*

Yes

No

Is this provider supportive of your claim for disability? 6*

Yes

No

I don't know

Do you have a seventh doctor/clinic to report?*

Yes

No

Doctor Name 7*

Clinic Name 7*

Clinic Address 7*

Street Address Address Line 2 City State ZIP Code

Doctor/Clinic Phone 7*

Medical Records Department Fax OR Email 7*

Are you still receiving treatment at this facility? 7*

Yes

No

Is this provider supportive of your claim for disability? 7*

Yes

No

I don't know

Do you have an eighth doctor/clinic to report?*

Yes

No

Doctor Name 8*

Clinic Name 8*

Clinic Address 8*

Street Address Address Line 2 City State ZIP Code

Doctor/Clinic Phone 8*

Medical Records Department Fax OR Email 8*

Are you still receiving treatment at this facility? 8*

Yes

No

Is this provider supportive of your claim for disability? 8*

Yes

No

I don't know

Do you have a ninth doctor/clinic to report?*

Yes

No

Doctor Name 9*

Clinic Name 9*

Clinic Address 9*

Street Address Address Line 2 City State ZIP Code

Doctor/Clinic Phone 9*

Medical Records Department Fax OR Email 9*

Are you still receiving treatment at this facility? 9*

Yes

No

Is this provider supportive of your claim for disability? 9*

Yes

No

I don't know

Do you have a tenth doctor/clinic to report?*

Yes

No

Doctor Name 10*

Clinic Name 10*

Clinic Address 10*

Street Address Address Line 2 City State ZIP Code

Doctor/Clinic Phone 10*

Medical Records Department Fax OR Email 10*

Are you still receiving treatment at this facility? 10*

Yes

No

Is this provider supportive of your claim for disability? 10*

Yes

No

I don't know

Do you have an eleventh doctor/clinic to report?*

Yes

No

Doctor Name 11*

Clinic Name 11*

Clinic Address 11

Street Address Address Line 2 City State ZIP Code

Doctor/Clinic Phone 11*

Medical Records Department Fax OR Email 11*

Are you still receiving treatment at this facility? 11*

Yes

No

Is this provider supportive of your claim for disability? 11*

Yes

No

I don't know

Do you have a twelfth doctor/clinic to report?*

Yes

No

Doctor Name 12*

Clinic Name 12*

Clinic Address 12*

Street Address Address Line 2 City State ZIP code

Doctor/Clinic Phone 12*

Medical Records Department Fax OR Email 12*

Are you still receiving treatment at this facility? 12*

Yes

No

Is this provider supportive of your claim for disability? 12*

Yes

No

I don't know

Do you have a thirteenth doctor/clinic to report?*

Yes

No

Doctor Name 13*

Clinic Name 13*

Clinic Address 13*

Street Address Address Line 2 City State ZIP Code

Doctor/Clinic Phone 13*

Medical Records Department Fax OR Email 13*

Are you still receiving treatment at this facility? 13*

Yes

No

Is this provider supportive of your claim for disability? 13*

Yes

No

I don't know

Do you have a fourteenth doctor/clinic to report?*

Yes

No

Doctor Name 14*

Clinic Name 14*

Clinic Address 14*

Street Address Address Line 2 City State ZIP Code

Doctor/Clinic Phone 14*

Medical Records Department Fax OR Email 14*

Are you still receiving treatment at this facility? 14*

Yes

No

Is this provider supportive of your claim for disability? 14*

Yes

No

I don't know

Do you have a fifteenth doctor/clinic to report?*

Yes

No

Doctor Name 15*

Clinic Name 15*

Clinic Address 15*

Street Address Address Line 2 City State ZIP Code

Doctor/Clinic Phone 15*

Medical Records Department Fax OR Email 15*

Are you still receiving treatment at this facility? 15*

Yes

No

Is this provider supportive of your claim for disability? 15*

Yes

No

I don't know

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Medical Development

Benefits Received

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