Please provide the following basic information about yourself and the legal problem that you are seeking Legal Aid's help with. * incdicates a required field.
City* State* Zip Code* Ward
Phone*
Email*
Date of Birth*
Who is on the other side of your case? (Name and birthdate, if applicable): BackNext
Type of Public Benefits issue: Social SecurityTANF (Temporary Aid for Needy Families)Food StampsMedicaid/Medicare/QMB/AllianceHome Health AideUnemployment Insurance
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
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 upload , e-mail (to onlineintake@legalaiddc.org) or fax them to 202.727.2132 (Attn: Online Intake)
A. All Social Security paperwork B. All medical records.
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
H. Have you filed an appeal of the overpayment? YesNo
What kind of appeal? Did Social Security stop any withholding of their benefits? YesNo
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? [texarea noticeofstoppage] 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 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
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?
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 child care 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
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.
Do you know why your health insurance got cut off? {text cutoffreason] Have you appealed the decision? YesNo
Please note: You have 90 days (from the date your insurance was cut off) to appeal the decision.
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
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.
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
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
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
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
Where did you last work? (Name of Employer) Have you applied for unemployment benefits with the DC Department of Employment Services (DOES)? YesNo
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
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