Client Updates - McDonald Disabililty

STEP 1: Please confirm current contact information

Client Name(Required)

Case Manager

Phone

Email

Street

City

State

Zip Code

STEP 2: Please confirm your alternate contact's information.

If nothing has changed click "Next".

Contact Name

Relationship

Contact Phone

Email

Street

City

State

Zip Code

STEP 3: Please update your financial information and work status.

Financial Information

Household Income

Living Arrangement (IE Family, Friends)

Have you worked since applying for Disability?(Required)

Employer 1:

Name

Street Address

City/State/Zip

Phone

Employment Information

Date Started

Date Ended

Hours Worked Per Day

Days Worked Per Week

Hourly Rate of Pay

Job Description

Add a 2nd Employer?

Employer 2:

Name

Street Address

City/State/Zip

Phone

Employment Information

Date Started

Date Ended

Hours Worked Per Day

Days Worked Per Week

Hourly Rate of Pay

Job Description

Add a 3rd Employer?

Employer 3:

Name

Street Address

City/State/Zip

Phone

Employment Information

Date Started

Date Ended

Hours Worked Per Day

Days Worked Per Week

Hourly Rate of Pay

Job Description

Add a 4th Employer?

Employer 4:

Name

Street Address

City/State/Zip

Phone

Employment Information

Date Started

Date Ended

Hours Worked Per Day

Days Worked Per Week

Hourly Rate of Pay

Job Description

STEP 4: Please update your medical treatments

Include as much information as you can.

Are you currently receiving medical treatment?(Required)

If yes:

Please complete the following to the best of your ability. It is extremely important that you fill in all of the blanks as completely and accurately as possible, so we may obtain the necessary medical records.

Please only include doctors and hospitals that you have seen since the last time you updated this form. We are aware of your medical providers prior to this date.

If you are unsure of any of the requested dates, please provide an estimated date. This is particularly important, because doctors and hospitals will not process requests for medical records unless the records are requested from a specific period.

Doctor / Clinic / HMO/ Therapist 1

Provider Name

Street Address

City/State/Zip

Phone

Patient ID (if known)

Visit Information

Reason for Visit

First Visit

Last Visit

Next Appointment

Treatment Received

Add a 2nd Doctor / Clinic / HMO/ Therapist / Other?

Doctor / Clinic / HMO/ Therapist 2

Provider Name

Street Address

City/State/Zip

Phone

Patient ID (if known)

Visit Information

Reason for Visit

First Visit

Last Visit

Next Appointment

Treatment Received

Add a 3rd Doctor / Clinic / HMO/ Therapist / Other?

Doctor / Clinic / HMO/ Therapist 3

Provider Name

Street Address

City/State/Zip

Phone

Patient ID (if known)

Visit Information

Reason for Visit

First Visit

Last Visit

Next Appointment

Treatment Received

Add a 4th Doctor / Clinic / HMO/ Therapist / Other?

Doctor / Clinic / HMO/ Therapist 4

Provider Name

Street Address

City/State/Zip

Phone

Patient ID (if known)

Visit Information

Reason for Visit

First Visit

Last Visit

Next Appointment

Treatment Received

STEP 6: Please update your pharmacy information and medication

Pharmacy Information

Pharmacy Name

Street Address

City/State/Zip

Phone

List the Name of Each Medication (prescribed and over-the-counter)

Medication Name

If Prescribed, Name of Prescribing Doctor

Reason for Medication

Side Effects

Click the + button to add additional medications

STEP 7: Please enter any additional information you would like to share with your Case Manager

Additional Information

Comments

This field is for validation purposes and should be left unchanged.

Regular updates strengthen your claim.

Regular updates strengthen your claim.

STEP 1: Please confirm current contact information

STEP 2: Please confirm your alternate contact's information.

STEP 3: Please update your financial information and work status.

STEP 4: Please update your medical treatments

STEP 5: Please update your hospital visits

STEP 6: Please update your pharmacy information and medication

STEP 7: Please enter any additional information you would like to share with your Case Manager