Benefit Eligibility Form

Patient Information


Are you currently working?

Are you currently treating with any doctors?

What conditions have you been diagnosed with?

Are your impairments expected to last at least 12m?

Have you worked five out of the last ten years?

Do you currently have a social security claim pending?


Contact Us For a Free Consultation

Driscoll Salazar Disability Group
8280 Aspen Ave., Ste 155
Rancho Cucamonga, CA 91730

217 N Main St., Ste 123
Santa Ana, CA 92701

Phone: 888-984-3734