2. WAGE EARNER, IF DIFFERENT 3. SOC. SEC. CLAIM NUMBER 4. SPOUSE's CLAIM NUMBER
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1 CF Attached: Title ; Title XVI; or Title CF held in FO to establish CAPS ORBIT; or CF requested: Title ; Title XVI SSI Aged/Title SSI Blind/Title CF attached: Title ; Title XVI CLAIMS FOLDER
2 CF Attached: Title ; Title XVI; or Title CF held in FO to establish CAPS ORBIT; or CF requested: Title ; Title XVI SSI Aged/Title SSI Blind/Title CF attached: Title ; Title XVI HEARING OFFICE FILE
3 CF Attached: Title ; Title XVI; or Title CF held in FO to establish CAPS ORBIT; or CF requested: Title ; Title XVI SSI Aged/Title SSI Blind/Title CF attached: Title ; Title XVI FIELD OFFICE
4 CF Attached: Title ; Title XVI; or Title CF held in FO to establish CAPS ORBIT; or CF requested: Title ; Title XVI SSI Aged/Title SSI Blind/Title CF attached: Title ; Title XVI REPRESENTATIVE
5 CF Attached: Title ; Title XVI; or Title CF held in FO to establish CAPS ORBIT; or CF requested: Title ; Title XVI SSI Aged/Title SSI Blind/Title CF attached: Title ; Title XVI CLAIMANT
6 PRIVACY ACT AND PAPERWORK ACT NOTICE The Social Security Act (sections 205(a), 702, 1631(e)(1)(A) and (B), and 1869(b)(1) and (c), as appropriate) authorizes the collection of information on this form. We need the information to continue processing your claim. You do not have to give it, but if you do not you may not receive benefits under the Social Security Act. We may give out information on this form without your written consent if we need to get more information to decide if you are eligible for benefits or if a Federal law requires us to do so. Specifically, we may provide information to another Federal, State, or local government agency which is deciding your eligibility for a government benefit or program; to the President or a Congressman inquiring on your behalf; to an independent party who needs statistical information for a research paper or audit report on a Social Security program; or to the Department of Justice to represent the Federal Government in a court suit related to a program administered by the Social Security Administration. We explain, in the Federal Register, these and other reasons why we may use or give out information about you. If you would like more information, get in touch with any Social Security Office. We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it. Explanations about these and other reasons why information about you may be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security office. The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 35 of the Paperwork Reduction Act of We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB control number. TIME IT TAKES TO COMPLETE THIS FORM We estimate that it will take you about 10 minutes to complete this form. This includes the time it will take to read the instructions, gather the necessary facts and fill out the form. If you have comments or suggestions on this estimate, write to the Social Security Administration, ATTN: Reports Clearance Officer, 1-A-21 Operations Bldg., Baltimore, MD Send only comments relating to our "time it takes" estimate to the office listed above. All requests for Social Security cards and other claims-related information should be sent to your local Social Security office, whose address is listed under Social Security Administration in the U.S. Government section of your telephone directory.
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PATIENT INTAKE PACKET
PATIENT INTAKE PACKET Welcome to the CannaMD family - you're in great hands! To reduce your visit and wait time, we ask that you please complete and submit this intake packet at least 24 hours prior to
Frequently Asked Questions about MOUs. 4. What information do I need to provide on the MOU form?
Frequently Asked Questions about MOUs Question List- Click on a question to go directly to the answer or scroll through the document. 1. What is an MOU? 2. Who needs to complete an MOU? 3. How do I access