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- Begin with Part A, where you will enter your personal information. Fill in your last name, first name, middle initial, mailing address, daytime phone number, email address, and social security number.
- Continue by providing your date of birth and gender. Describe your disability in detail, including how and when it occurred. Make sure to answer whether you have recovered from this disability.
- In Part B, ensure that your health care provider completes their section accurately. They must provide their diagnosis and treatment dates related to your disability.
- Review all entries for accuracy before submitting. Use our platform's features to save or print the completed form for submission.
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