Medical Development "*" indicates required fields Step 1 of 16 6% Name* 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? 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? 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 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 Treatment Start Date*At least month and year Next Appointment Date (If applicable) 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 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 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 Treatment Start Date 2*At least month and year Next Appointment Date (If applicable) 2 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 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 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 Treatment Start Date 3*At least month and year Next Appointment Date (If applicable) 3 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 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 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 Treatment Start Date 4*At least month and year Next Appointment Date (If applicable) 4 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 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 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 Treatment Start Date 5*At least month and year Next Appointment Date (If applicable) 5 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 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 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 Treatment Start Date 6*At least month and year Next Appointment Date (If applicable) 6 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 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 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 Treatment Start Date 7*At least month and year Next Appointment Date (If applicable) 7 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 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 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 Treatment Start Date 8*At least month and year Next Appointment Date (If applicable) 8 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 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 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 Treatment Start Date 9*At least month and year Next Appointment Date (If applicable) 9 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 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 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 Treatment Start Date 10*At least month and year Next Appointment Date (If applicable) 10 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 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 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 Treatment Start Date 11*At least month and year Next Appointment Date (If applicable) 11 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 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 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 Treatment Start Date 12*At least month and year Next Appointment Date (If applicable) 12 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 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 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 Treatment Start Date 13*At least month and year Next Appointment Date (If applicable) 13 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 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 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 Treatment Start Date 14*At least month and year Next Appointment Date (If applicable) 14 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 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 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 Treatment Start Date 15*At least month and year Next Appointment Date (If applicable) 15 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