APPLICATION FOR DISABILITY INSURANCE BENEFITS. Page 1 of 7 OMB No. 0960-0618. I apply for a period of disability and/or all insurance benefits for which I am eligible under Title II and Part A of Title XVIII of the Social Security Act, as presently amended. (Do not write in this space) 1. PRINT your name. FIRST NAME, MIDDLE INITIAL, LAST NAME 2.
Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give
APPLICATION FOR SUPPLEMENTAL SECURITY INCOME (SSI) Form Approved OMB No. 0960-0229. Page 1. TEL Note: Social Security Administration staff or others who help people apply for SSI will fill out this form for you. I am/We are applying for Supplemental Security Income and any federally administered state supplementation under Title XVI of the Social
Plan of Action (Outlines actions that the subordinate will do after the counseling session to reach the agreed upon goal(s). The actions must be
to release to U.S. Citizenship and Immigration Services all relevant physical and mental health information related to my medical status for the purpose of applying for an exception from the English language and U.S. civics requirements for naturalization. I certify under penalty of perjury,
Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. 2. Business name/disregarded entity name, if different from above. 3. Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only . one. of the following seven boxes. Individual/sole ...
To enroll in a Health Maintenance Organization (HMO), you must live (or in some cases work) in a geographic area specified by the carrier. To enroll in an employee organization plan, you must be or become a member of the plan’s sponsoring organization, as specified by the carrier. Your signature in Part H authorizes deductions from your salary,
The National Provider Identifier (NPI) is the standard unique health identifier for health care providers and is assigned by the National Plan and Provider Enumeration System (NPPES). As a Medicare health supplier, you must obtain an NPI prior to enrolling in Medicare or before submitting a change for your existing Medicare enrollment information.
To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and, 4. To facilitate statistical research, audit, or investigative activities necessary to assure the ... Statement of claimant or other person, SSA-795, 795
SUMMARY of CHANGE AR 600–9 The Army Body Composition Program This major revision, dated 28 June 2013-o Changes the name of the regulation from the Army Weight Control Program to the
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