To secure services for your client, please enter the following information and click the Submit button. An SSDLA representative will contact you regarding the feasibility of the case.

Procedure Requested
Proceed with assistance if case is feasible
Hold for additional authorization if case is feasible
 
Claimant Information
Claimant*:
Specialist's Name:
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City:
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Age / Date of Birth:
 
Diagnosis:
 
Date Disabilty Began:
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