SSA Referral

SSA Referral
SSA		SSA Manager
Date of Referral
Individual's Name
Address
Lives with
Phone
Best time of day to reach individual
Work site & schedule
Assistance needed
State specific dates/timelines if applicable
Other information about the individual that would be helpful for support person to know (e.g., Mobility, Behavioral, Medical issues.)
IF TASK IS MEDICALLY RELATED - the following information must be provided
Known medical diagnosis
Doctor’s name, address, specialty, phone
Purpose of visit/presenting problem
List of current meds
Self-medication status
Pharmacy of choice, phone
Applicable Medicaid, Medicare, Medicare RX coverage(Copies of all cards to be sent via inter-office mail)
Confirmation of copay