National Social Security Disability Assistance
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Contact us
To contact the Social Security Resource Center, please fill out the form below for a free, no obligation disability evaluation. A representative will contact you within one day of receiving your submission.
If you are applying for someone else, click here.

First Name *
Last Name *
Address
Address Other
(Apartment #, Suite #, etc.)
City *
State *
  
Zip Code
Phone *
  
Alternate Phone
Email Address *
  
Date Of Birth
(mm/dd/yyyy)
Gender
I need help:
Are you currently working?
Are you receiving Social Security retirement benefits?
Have you visited a doctor in the last 12 months about your condition?
 
Do you have health insurance?
 
What is your medical condition?
List your prescription medications: (one per line)

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