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Public Benefits Intake

Section A: Basic Information

Please provide the following basic information, which will be used to perform a conflicts check. If we are unable to assist you based on this information, we will not review and will delete from our systems the information in the following sections. * indicates a required field.
WhiteBlackHisp./LatinoAsianPacific Island.Native Amer.Biracial/MultiracialPrefer Not to AnswerOther
FemaleMaleGender NonconformingPrefer Not to AnswerOther:
By applying for legal assistance online you are agreeing to be contacted by all methods. If you prefer not to be contacted by these methods please call the intake line at 202-628-1161. Press option 1, then press option 2.

Section B: Household Income

Legal Aid generally serves individuals whose household income is at or below 200% of the Federal Poverty Guidelines. For some types of cases, we may serve individuals whose household income is between 200% and 300% of the Federal Poverty Guidelines. Please provide the following basic information about your household income so that we can determine whether you are eligible for our services. If we are unable to assist you for any reason, this information in this section will be deleted from our system.
Type of Income
Amount
Frequency
Type of Income
Amount
Frequency
Type of Income
Amount
Frequency
Type of Income
Amount
Frequency
Type of Income
Amount
Frequency

Section C: Information about Your Legal Matter

Please provide the additional information below describing your legal matter. If we are unable to provide you with legal representation on this matter for any reason, the information in this section will be deleted from our system. Type of Public Benefits issue: Social SecurityTANF (Temporary Aid for Needy Families)Food StampsMedicaid/Medicare/QMB/AllianceHome Health AideUnemployment Insurance
SOCIAL SECURITY I applied for Social Security and was denied Note: If you applied and have NOT yet been denied, then please re-apply if/when you are denied.I was receiving Social Security benefits, but they were reduced/terminated.I receive or received Social Security and have been charged with an overpayment
I applied for Social Security and was denied I. What type of Social Security benefit(s) did you apply for? (SSI, SSDI, Survivors benefits, etc.) II. Are you asking for help with a Request for Reconsideration appeal (first level of appeal) or a Hearing appeal (second level of appeal)? III. What is the date on the most recent Social Security denial notice you received? IV. Did you file an appeal within 65 days of the most recent denial? YesNo

i. When did you file? ii. How did you file? (by visiting office, mail, etc.) iii. Do you have a copy of the appeal paperwork?

i. Are you still within that 65-day time period? YesNo

Please file the appeal before hearing back from us and ask for a date-stamped copy of the appeal.
Why did you miss the deadline? (problems with mail, in hospital, homeless, etc.)

I was receiving Social Security benefits, but they were reduced/terminated. I. What type of benefits were you receiving? SSI, Child’s SSI, SSDI, Survivor’s benefits, etc. II. Did you ask to have your benefits continue pending your appeal? YesNo
I. What are ALL of your medical conditions that keep you from working?

a. What are the symptoms of these conditions? b. How long have you had them? c. How do these symptoms limit your ability to work? d. How frequently do the symptoms occur? How severe are they?

II. Where do you go for health care? List all of your doctors (and the type– primary care, cardiologist, etc.) III. Do you have current or past issues with substance abuse? (We ask this because it is something that the SSA will ask about.) YesNo

i. What substances? ii. CurrentPast

a. How long have you been using for? b. Have you ever been in rehab? YesNo

a. How long were you using for? b. How long have you been clean? c. Have you ever been in rehab? YesNo

IV. What is the highest grade of school you completed? V. Were you ever in special education classes? If so, for what? VI. Are you currently working? YesNo

i. How much do you earn per month?

i. When was the last time you worked? ii. What kind of job was it? iii. What did Applicant do in the job? iv. Why did the job end?

VII. Please list all jobs you have held in the past 15 years, including the following details for each job: a. Around when did the job begin and around how long did it last (a few months? A year? Longer than a year)? b. What were your job duties? c. Why did the job end? IMPORTANT DOCUMENTS IN SOCIAL SECURITY CASES If you have any of the following documents, please send them to us via one of the following methods: upload them using the button below, e-mail them to onlineintake@legalaiddc.org, or fax them to 202-727-2132 (Attn: Online Intake): A. All Social Security paperwork B. All medical records Upload and email limit 25 MB
I receive or received Social Security and have been charged with an overpayment A. What is the amount of the overpayment? B. Did you receive a notice from Social Security about the overpayment? If not, how did you find out about the overpayment? C. If you were given a reason for the overpayment, what was it? D. Do you agree with Social Security’s explanation? If not, what do you think Social Security got wrong about the overpayment? E. If Social Security claims that you failed to report other income:

1. What is the source of the other income? 2. Did you get the income Social Security thinks you did? YesNo 3. Did you report income to Social Security? If so, how? 4. Did you report income when it was received, or did you report it later? If later, how much later – after Social Security told you you were overpaid? F. Is Social Security taking money out of your check to pay down the overpayment? YesNo

When did the withholding start? How much are they taking every month? G. Do you have Medicare? YesNo

Do you also have Medicaid or QMB?

H. Have you filed an appeal of the overpayment? YesNo

What kind of appeal? Did Social Security stop any withholding of their benefits? YesNo

Here is a link to information on how to deal with a Social Security Overpayment. Please note that you have 60 days (from the date of the overpayment notice) to file a reconsideration appeal, if you disagree that the overpayment occurred or think Social Security has the wrong amount.
IMPORTANT DOCUMENTS IN SOCIAL SECURITY OVERPAYMENT CASES If you have any of the following documents, please upload , e-mail (to onlineintake@legalaiddc.org) or fax them to 202.727.2132 (Attn: Online Intake) - All Social Security notices and paperwork - If Social Security says your unreported earnings caused the overpayment, any paystubs from time frame of the overpayment.
TANF 1. How much TANF do you get (or were you getting, until problems started) each month? For how many family members? 2. What problem are you having with TANF? TANF stoppedTANF was reducedTANF application deniedApplied for TANF, but haven’t heard anything

TANF stopped

When did your benefits stop? Did you get any notice about your benefits stopping? If so, what did it say? How much were you getting before your benefits stopped?

TANF was reduced

When were your benefits reduced? Did you get any notice about your benefits being reduced? If so, what did it say? How much were you getting before your benefits were reduced?

TANF application denied

When did you apply? Did DHS say why you were denied? Do you disagree with their decision?

Applied for TANF, but haven’t heard anything

When did you apply?

3. Did you submit all the paperwork you were supposed to submit? YesNo

When and where did you submit it?

Why not?

4. Did you appeal? YesNo

When? Do you have a hearing or pre-hearing conference scheduled? If so, which one and when is it?

5. We need the following information to figure out how much TANF you should be getting:

a. How long have you been receiving TANF? b. Does your family have any other income?

i. Child support? ii. SSI for you or a child? iii. Income from working?

c. Do you have any barriers that would keep you from work activities or job searches for 20-30 hours per week?

iv. Recent domestic violence? v. Your own disability? vi. Your child’s disability?

IMPORTANT DOCUMENTS IN TANF CASES If you have any of the following documents, please send them to us via one of the following methods: upload them using the button below, e-mail them to onlineintake@legalaiddc.org, or fax them to 202-727-2132 (Attn: Online Intake): Any papers you received from DHS Any papers you gave to DHS Any other papers you think are relevant Upload limit 25 MB
Food Stamps 1. How much in Food Stamps do you get (or were you getting, until problems started) each month? For how many household members? 2. What problem are you having with Food Stamps? Food Stamps stoppedFood Stamps were reducedFood Stamps application deniedApplied for Food Stamps, but haven’t heard anything

Food Stamps stopped When did your benefits stop? Did you get any notice about your benefits stopping? If so, what did it say? How much were you getting before your benefits stopped?

Food Stamps was reduced When were your benefits reduced? Did you get any notice about your benefits being reduced? If so, what did it say? How much were you getting before your benefits were reduced?

Food Stamps application denied When did you apply? Did DHS say why you were denied? Do you disagree with their decision?

Applied for Food Stamps, but haven’t heard anything When did you apply?

3. Did you submit all the paperwork you were supposed to submit? YesNo

When and where did you submit it?

Why not?

4. Did you appeal? YesNo

When? Does you have a hearing or pre-hearing conference scheduled? If so, which one and when is it?

We need the following information to figure out how much in Food Stamps you should be getting:

a. How many people in your household buy and/or prepare meals together? b. Please list the income for everyone in your household who buy and/or prepare meals together. This includes earned income (wages) and unearned income (like Social Security and TANF). c. How much do you pay in rent or mortgage every month? d. If applicable, how much do you pay in child support every month? e. Do you have any medical expenses that are not covered by insurance? If so, how much? f. If applicable, how much do you pay in childcare expenses every month? g. What is your immigration status? Note: we do not care about your status and will try to serve you regardless. However, Food Stamps eligibility depends (in part) on immigration status.

IMPORTANT DOCUMENTS IN FOOD STAMPS CASES If you have any of the following documents, please upload , e-mail (to onlineintake@legalaiddc.org) or fax them to 202.727.2132 (Attn: Online Intake) Any papers you received from DHS Any papers you gave to DHS Any other papers you think are relevant
Medicaid/Medicare/QMB/Alliance My health insurance got cut off.I cannot get Medicaid/Medicare/QMB/Alliance to cover a procedure or drug I need.I have medical bills I cannot pay. Questions for all health insurance issues What type of health insurance do you have? Note: If you are not sure, please look at your card for the following: Medicare cards are red, white, and blue and have a “claim number” (usually the Social Security number plus a letter/dates for Parts A and B); Medicaid cards are either blue or white and say “DC Medical Assistance,” OR have the name of a managed care organization on them (Amerihealth, Trusted, MedStar Choice); QMB cards say “Qualified Medicare Beneficiary” on them; and Alliance cards are from a managed care organization (Amerihealth, Trusted, MedStar Choice) AND say Alliance on them.
1. My health insurance got cut off.

Do you know why your health insurance got cut off? {text cutoffreason] Have you appealed the decision? YesNo

Do you have a hearing date?

Please note: You have 90 days (from the date your insurance was cut off) to appeal the decision.

2. I cannot get Medicaid/Medicare/QMB/Alliance to cover a procedure or drug I need.

Does your problem involve getting Medicare to cover a prescription drug that you need? YesNo

Please email to onlineintake@legalaiddc.org or fax to 202.727.2132 us a copy of your Medicare card (red, white and blue card) and your prescription drug list. Your prescription drug list should include: Name of the drug If you can take generic version Dosage How often you need to take it a day or week

What medical procedure or thing is not being covered?

How does your inability to get this procedure or thing affect you? And how often does it affect you (on a daily, weekly, monthly basis, etc.)? Does your doctor or dentist believe that this procedure or thing is medically necessary? Have you appealed the denial of coverage? YesNo

Do you have a hearing date?

Please note: You have 90 days (from the date of the denial notice) to appeal the decision.

3. I have a medical bill I cannot pay.

A. Did you have Medicaid/Medicare/QMB/Alliance at the time of the service? If yes, which one? B. Did you tell your provider about your insurance at the time of the service? YesNo

As a first step, please call your provider and tell them about your insurance to see if this resolves the problem.
IMPORTANT DOCUMENTS IN HEALTH INSURANCE CASES If you have any of the following documents, please upload , e-mail (to onlineintake@legalaiddc.org) or fax them to 202.727.2132 (Attn: Online Intake) 4. Copy of health insurance card(s) 5. Any notices you got from DHS about your health insurance 6. Any medical bills
Home Health Aide I. Were you denied services or are you appealing a decision to reduce/terminate the number of home health aide hours you receive? Applied but denied servicesAppealing decision to reduce/terminate number of home health aide hours

1. How many hours per day AND how many days per week of home health services were you getting before the reduction or termination? 2. How many hours per day AND how many days per week will you now receive (if any), per the agency’s recent decision? 3. What is the name of the home health agency providing the care? 4. What is the name of the home health agency providing case management?

II. Why were you denied or why were the home health aide hours reduced/terminated? Over-incomeOther reason:

Do you have any outstanding medical expenses that insurance has not paid for? YesNo

Please list the dates and amounts of all of your outstanding medical bills.

III. Did you get a written notice of the decision? If not, how did you find out about the decision? IV. What are your medical conditions? V. How do they affect your ability to do things around the home? VI. Please describe in as much detail as possible how the aide helps you (or a potential aide would help you) with the following, if you need the help:

a. Bathing: b. Dressing: c. Toileting: d. Walking/Ambulating: e. Managing your medicines: f. Preparing your meals: g. Eating your meals: h. Helping with chores:

VII. Who are doctors/medical providers most familiar with your need for home health services? VIII. Are there any friends/relatives who are familiar with your needs? IX. Have you filed an appeal with the Office of Administrative Hearings? YesNo

i. Did you ask that services be continued at the existing level during the appeal? ii. Do you have a hearing or status conference scheduled? If so, when?

Please note: You have 90 days from the date of the notice to file an appeal.

IMPORTANT DOCUMENTS IN HOME HEALTH AIDE CASES If you have any of the following documents, please upload , e-mail (to onlineintake@legalaiddc.org) or fax them to 202.727.2132 (Attn: Online Intake) A. Notices / decision letters B. Medical records C. Other relevant documents that you have
Unemployment Insurance Where was your last job located? Note: If your last job was split between states, then where was your job mostly located? DCMDVAAnother state
Even if you are a DC resident, we are unable to give you legal advice because your matter is a Maryland or Virginia one (depending on which state you selected), and we are not licensed to practice law in these states. However, please visit the Washington Lawyer’s Committee Workers Rights Clinic for advice because they have attorneys licensed to practice law in Maryland, Virginia, and DC. http://www.washlaw.org/projects/workers-rights-clinic
Even if you are a DC resident, your unemployment insurance case is located in the state where you worked. Therefore, you will need to talk to a lawyer licensed to practice law in that state. To find legal assistance in another state, please visit https://www.lawhelp.org/
Where did you last work? (Name of Employer) Have you applied for unemployment benefits with the DC Department of Employment Services (DOES)? YesNo
What is the status of the application? Have you received a denial letter (called a Determination by Claims Examiner)? YesNo
Have you (or the employer) appealed the decision? Please note: the deadline for appealing these decisions is 15 calendar days from the date on the notice. YesNo
Has a hearing date been scheduled? This usually happens 2-3 weeks after an appeal is filed. YesNo
What is the date of your hearing? If you already had your hearing, then please answer these additional questions: What was the outcome? Did you receive a final order in the mail? Did you appeal any unfavorable decision to the DC Court of Appeals within 30 days?
Why did your last job end? Did you quit, were you terminated, or were you laid off? Please describe in detail what happened before your last job ended. Did you get into any arguments with anyone, for example? What was your relationship with your co-workers and boss like? Did you ever receive any write-ups at your job for problems on the job? Did your employer ever threaten to give you a write-up? Did you ever receive any awards/promotions at your job for good performance?
IMPORTANT DOCUMENTS IN UNEMPLOYMENT INSURANCE CASES If you have any of the following documents, please upload , e-mail (to onlineintake@legalaiddc.org) or fax them to 202.727.2132 (Attn: Online Intake) Any notices you received from the DC Office of Employment Services Any notices your employer gave you concerning your job ending Anything you signed and gave to your employer concerning your job ending Any other documents related to your unemployment insurance case