Sample Phone Intake Form

Name: _________________________________________     Interviewer:                                                           

Address:                                                                                                   Date:                                                      

Phone:                                                            

Referred by: ______________________________ Name of caller:                                                                       

Type of claim:           __ SSD           __  SSI               __ SSD/Widow/er            __ Worker’s Compensation

AGE: ______    Education: __________    Date Last Worked: _________   Telephoned before:  __

Prior work experience:                                                                                                                                                            

Describe impairments/injury:                                                                                                                                                                                                                                                                                                                                                    
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        

SSA:    __   Initial contact (PF)                                              

__   Initial app                                                             

__   Initial denial                                                              Why                                                                          

__   Recon not requested

__   Recon requested                                                   

            __   Recon denial                                                             Why                                                                          

__   Hearing not requested

__   Hearing requested                                              

__   Hearing scheduled                                                    ALJ                                                                                           

            __   Hearing denial                                                          Where you represented                                            

                   ALJ                                                                             By who                                                                

            __   Request for review not filed                                   When was your attorney released                                       

            __   Request for review filed                                          Decision received by                                              

                   Employer                                                                   Insurance Carrier                                                     

            __   Date of injury                                                            Type of Injury                                                         

__   No dispute

__   Dispute                                                                                                                                                         

__   Causation                                                                                                                                                     

__   IME                                                                            DR.                                                                            

__   Healing Plateau                                                   

__   PPD Conceded                                                    

__   Issues                                                                                                                                                            

IMPAIRMENTS                                                                                                                                                                  

TREATMENT/DOCTORS                                                                                                                                                 

RESTRICTIONS 

MEDICATIONS                                                                                                                                                                  

ISSUES                                                                                                                                                                                 

Appointment:  Day: __________   Date:__________   Time:__________

Rep: __________  Scheduler’s Initials:______ Type of Letter:                                                                                

Questionnaires: __ SSA   __ WC   __ TERM  __ Psych __ Supplemental

OTHER: ___________ SEND:  __ Can’t Reach letter    __  Brochures    __ Kit  __

Declined.  Reason: