Provider Referal

Disability Specialists strives to make the Social Security Disability application as simple and straightforward as possible for your clients.

We work in 120 different languages. When you call, state the language you prefer, then wait a moment while we get someone on the line to help.

To request an intake interview, choose your option, and we’ll begin the process:
Call: 1-800-642-6393
Fax: request a fax form
Questionnaire: see Below

    All fields with * are required for submission.

    Have they started an application for Social Security benefits?

    Is your client currently working and earning more than $1,310 per month?

    Are they able to perform any full time job that they have done in the past 15 years?

    Do they have a severe physical and/or mental condition?

    Will they miss at least 12 months of work because of the condition or have they already missed 12 months of work because of the condition?

    Has the client received treatment from a doctor for their condition?

    Name*:                        

    Phone*:                      

    Email*:                      

    Street Address*:      

    Address Line 2:      

    City*:                             

    State*:                          

    Zip*:                              

    Date of Birth* (mm/dd/yyyy) :  

    Best time of day to contact the applicatant?*  

    We request your information if we have difficulties contacting the potential applicant for an intake interview.
    Provider Information:
    Organization*:
    Your Name*:
    Phone*:
    Email*:
    Would you like a follow-up on this submission?

    Would you like to have our Marketing Rep contact you to get more information about Disability Specialists?

    The applicant will get an automated email alerting them to the submission with your name and organization included.