I. Why? What has happened when you attempted to apply?
I. What type(s) of Social Security benefits did you apply for? (i.e., Supplemental Security Income (SSI), child SSI, Social Security Disability Insurance (SSDI), widow's benefits, survivor’s benefits, etc.)
III. What is the date on the most recent Social Security denial notice you received?
i. When did you file?
ii. How did you file? (by visiting office, mail, etc.)
iii. Do you have a copy of the appeal paperwork?
Why did you miss the deadline? (problems with mail, in hospital, homeless, etc.)
I. What type of benefits were you receiving? SSI, Child’s SSI, SSDI, Survivor’s benefits, etc.
I. What are ALL of your medical conditions that keep you from working?
a. What are the symptoms of these conditions?
b. How long have you had them?
c. How do these symptoms limit your ability to work? For example, would you have trouble getting along with coworkers, or concentrating, sitting, or standing for long periods of time)?
d. How frequently do the symptoms occur? How severe are they?
II. Where do you go for health care? List all of your doctors (and the type– primary care, cardiologist, etc.)
i. What substances?
a. How long have you been using for?
a. How long were you using for?
b. How long have you been clean?
IV. What is the highest grade of school you completed?
V. Were you ever in special education classes? If so, for what?
i. How much do you earn per month?
ii. When was the last time you worked?
iii. What kind of job was it?
iv. What did you do in the job? (Ex: lifted boxes, drove vehicles, etc.)
v. Why did the job end?
VIII. Is there anything else we should know about your case?
A. What is the amount of the overpayment?
B. Did you receive a notice from Social Security about the overpayment? If not, how did you find out about the overpayment?
C. If you were given a reason for the overpayment, what was it?
D. Do you agree with Social Security’s explanation? If not, what do you think Social Security got wrong about the overpayment?
1. What is the source of the other income?
3. Did you report income to Social Security? If so, how?
4. Did you report income when it was received, or did you report it later? If later, how much later – after Social Security told you you were overpaid?
When did the withholding start?
How much are they taking every month?
Do you also have Medicaid or QMB?
What kind of appeal (Request for Reconsideration, Request to Waive Overpayment, or both)?
I. Is there anything else we should know about your case?
1. How much TANF do you currently receive? For how many family members?
a. When did/will your benefits stop?
b. Did you get any notice about your benefits stopping? If so, what did it say?
c. How much TANF were you receiving before your benefits stopped?
When were your benefits reduced?
a. Did you get a letter from the Department of Human Services (DHS) about your benefits being reduced? If so, what did it say?
b. How much were you receiving before your benefits were reduced?
When did you apply?
a. Did the Department of Human Services (DHS) say why you were denied?
b. Do you disagree with their decision?
When did you apply?
a. When and where did you submit it?
b. To the best of your memory, please list the documents you submitted.
Why not?
When?
Do you have a hearing or pre-hearing conference scheduled? If so, which one and when is it?
a. How long have you been receiving TANF? OR How long were you receiving TANF for before it got cut off?
b. Does your family have any other income?
i. Child support?
ii. SSI? Please include the name(s) of the person(s) receiving SSI, including children.
iii. Income from working?
c. Do you have any barriers that would keep you from work activities or job searches for 20-30 hours per week?
i. Recent domestic violence?
ii. Your own disability?
iii. Your child’s disability?
Is there anything else we should know about your case?
1. How much in Food Stamps are you currently receiving each month? For how many household members?
a. When did your benefits stop?
b. Did you get any notice about your benefits stopping? If so, what did it say?
c. How much were you getting before your benefits stopped?
a. When were your benefits reduced?
b. Did you get any notice about your benefits being reduced? If so, what did it say?
c. How much were you getting before your benefits were reduced?
a. When did you apply?
b. Did the Department of Human Services (DHS) say why you were denied?
c. Do you disagree with their decision?
a. When did you apply
a. When and where did you submit it?
b. To the best of your memory, please list the documents you submitted. For example, proof of income, proof of rent, proof of residency, children's birth certificate, proof of bank account, or other resources.
Why not?
When?
Do you have a hearing or pre-hearing conference scheduled? If so, which one and when is it?
a. How many people in your household buy and/or prepare meals together? Please include adults and children.
b. Please list the income for everyone in your household who buy and/or prepare meals together. This includes earned income (wages) and unearned income (like Social Security, TANF, and child support).
c. How much do you pay in rent or mortgage every month?
1. Which utilities are you paying?
e. If applicable, how much do you pay in child support every month?
f. Do you have any medical expenses that are not covered by insurance? If so, how much?
g. If applicable, how much do you pay in childcare expenses every month?
h. Please list the immigration status of you and everyone in your household, including each child. (Note: immigrant parents may apply for food stamps for their U.S. citizen or qualified immigrant children, even though the parents may not be eligible for food stamps.)
Is there anything else we should know about your case?
2. When did your health insurance get cut off?
3. Do you know why your health insurance got cut off?
5. If you received Medicaid, QMB or Alliance, when is the last time you recertified for this benefit?
a. Do you have a hearing date?
a. What medical procedure or thing is not being covered?
b. How does your inability to get this procedure or thing affect you? And how often does it affect you (on a daily, weekly, monthly basis, etc.)?
c. Does your doctor or dentist believe that this procedure or thing is medically necessary?
i. Do you have a hearing date?
A. Did you have Medicaid/Medicare/QMB/Alliance at the time of the service? If yes, which one(s)?
Is there anything else we should know about your case?
Hearing date
1. How many hours per day AND how many days per week of home health services were you getting before the reduction or termination?
2. How many hours per day AND how many days per week will you now receive (if any), per the agency’s recent decision?
3. What is the name of the home health agency providing the care?
4. What is the name of the home health agency providing case management?
Other reason
Please list the dates and amounts of all of your outstanding medical bills.
III. Did you get a written notice of the decision? If not, how did you find out about the decision?
IV. What are your medical conditions?
V. How do they affect your ability to do things around the home?
a. Bathing:
b. Dressing:
c. Toileting:
d. Walking/Ambulating:
e. Managing your medicines:
f. Preparing your meals:
g. Eating your meals:
h. Helping with chores:
VII. Who are doctors/medical providers most familiar with your need for home health services?
VIII. Are there any friends/relatives who are familiar with your needs?
ii. Do you have a hearing or status conference scheduled? If so, when?
X. Is there anything else we should know about your case?
2. Where did you last work? (Name of Employer)
I. Why? What has happened when you attempted to apply?
ii. What is the date of your hearing?
iii. What was the outcome?
iv. Did you receive a final order in the mail?
v.Did you appeal any unfavorable decision to the DC Court of Appeals within 30 days?
b. Why did your last job end? Did you quit, were you terminated, or were you laid off?
c. Please describe in detail what happened before your last job ended. Did you get into any arguments with anyone, for example?
d. What was your relationship with your co-workers and boss like?
e. Did you ever receive any write-ups at your job for problems on the job? Did your employer ever threaten to give you a write-up?
f. Did you ever receive any awards/promotions at your job for good performance?
A. What is the amount of the overpayment?
B. Did you receive a notice from the D.C. Department of Employment Services (DOES) about the overpayment? If not, how did you find out about the overpayment?
C. If you were given a reason for the overpayment, what was it?
D. Do you agree with the explanation? If not, what do you think the agency got wrong about the overpayment?
i. What is the source of the other income?
iii. Did you report income to DOES? If so, how?
iv. Did you report income when it was received, or did you report it later? If later, how much later -- after DOES told you you were overpaid?
i. What happened at the hearing? What did the judge decide?
3. Is there anything else we should know about your case?