Medical Development "*" indicates required fields Step 1 of 16 6% Name (as it appears on your Social Security card)* First Last Date of Birth* MM slash DD slash YYYY Phone*Benefits ReceivedHave you ever received Workers Compensation Benefits? (L&I, Labor andIndustries, etc.)* Yes No If so, when? L&I Contact Name L&I Contact PhoneL&I Contact Fax/Email L&I Contact Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 PhoneFMLA, ST or LT Disability Contact Fax/Email FMLA, ST or LT Disability Contact Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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* List all doctors you have seen at this clinic* Clinic Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Doctor/Clinic Phone*Medical Records Department Fax OR Email* Are you still receiving treatment at this facility?* Yes No Approximate first date of service (MM/YYYY)* Approximate last date of service (MM/YYYY)* 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* List all doctors you have seen at this clinic 2* Clinic Address 2* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Approximate first date of service (MM/YYYY) 2* Approximate last date of service (MM/YYYY) 2* 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 List all doctors you have seen at this clinic 3 Clinic Address 3 Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Approximate first date of service (MM/YYYY) 3* Approximate last date of service (MM/YYYY) 3* 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* List all doctors you have seen at this clinic 4* Clinic Address 4* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Approximate first date of service (MM/YYYY) 4* Approximate last date of service (MM/YYYY) 4* 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* List all doctors you have seen at this clinic 5* Clinic Address 5* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Approximate first date of service (MM/YYYY) 5* Approximate last date of service (MM/YYYY) 5* 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* List all doctors you have seen at this clinic 6* Clinic Address 6* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Approximate first date of service (MM/YYYY) 6* Approximate last date of service (MM/YYYY) 6* 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 Clinic Name 7* List all doctors you have seen at this clinic 7* Clinic Address 7* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Approximate first date of service (MM/YYYY) 7* Approximate last date of service (MM/YYYY) 7* 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 Clinic Name 8* List all doctors you have seen at this clinic 8* Clinic Address 8* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Approximate first date of service (MM/YYYY) 8* Approximate last date of service (MM/YYYY) 8* 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 Clinic Name 9* List all doctors you have seen at this clinic 9* Clinic Address 9* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Approximate first date of service (MM/YYYY) 9* Approximate last date of service (MM/YYYY) 9* 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 Clinic Name 10* List all doctors you have seen at this clinic 10* Clinic Address 10* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Approximate first date of service (MM/YYYY) 10* Approximate last date of service (MM/YYYY) 10* 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 Clinic Name 11* List all doctors you have seen at this clinic 11* Clinic Address 11 Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Approximate first date of service (MM/YYYY) 11* Approximate last date of service (MM/YYYY) 11* 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 Clinic Name 12* List all doctors you have seen at this clinic 12* Clinic Address 12* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Approximate first date of service (MM/YYYY) 12* Approximate last date of service (MM/YYYY) 12* 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 Clinic Name 13* List all doctors you have seen at this clinic 13* Clinic Address 13* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Approximate first date of service (MM/YYYY) 13* Approximate last date of service (MM/YYYY) 13* 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 Clinic Name 14* List all doctors you have seen at this clinic 14* Clinic Address 14* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Approximate first date of service (MM/YYYY) 14* Approximate last date of service (MM/YYYY) 14* 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 Clinic Name 15* List all doctors you have seen at this clinic 15* Clinic Address 15* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Approximate first date of service (MM/YYYY) 15* Approximate last date of service (MM/YYYY) 15* Is this provider supportive of your claim for disability? 15* Yes No I don't know Untitled
