Disability Screening Form

ElevatePFS helps individuals determine if they are potentially eligible for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). If you or someone you know has been unable to work for 12 months or more because of a disabling condition, we may be able to help. Our initial consultation is at no cost to you – fill out the form below to begin the screening process.

Disability Screening

I am

Please list the name of the Health Plan, Hospital or Provider that is referring this patient/member:

Member ID or Account Number, if available

Disabled Individual’s Name:

First Name

Last Name

Disabled Individual’s Phone Number 1

Disabled Individual’s Phone Number 2

Disabled Individual’s Email

Is the disabled individual currently working?

Hours per week?

Average monthly gross pay?

Referring Individual's Name

First

Last

Referring Individual's Title/Relationship to Disabled Individual

Referring Individual's Email

Referring Individual's Phone

Comments

If you are human, leave this field blank.

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25700 Interstate 45 North, Suite 300
Spring, Texas 77386

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Disability Screening Form

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