Information RequestWhen you apply for services from SIRSS our Screening Specialist will ask for the following basic information:
Name: _____________________________________________________________ SSN: ______________________________________________________________ Address: ___________________________________________________________ Telephone: (Home) _____________ (Cell) ____________ (Work) _____________
Please check all methods that are acceptable for contacting you about services:
Phone: r (at Home) r (on Cell) r (at Work) r Via Letter: r Can we identify us as SIRSS when we call you? r Yes r No Additional Contact Information: ___________________________________________________________________ Age: ____ Gender: r Female r Male Date of Birth: _____________________ Marital Status: ____________________________ Employer: __________________________________________________________ Primary Language: ___________________________________________________ Insurance Provider: __________________________________________________ Insurance ID#:______________________________________________________ Medicaid Eligible? r Yes r No If yes, Medicaid #: _______________________ Medicare Eligible? r Yes r No Are you receiving or have you recently applied for disability? r Yes r No Which, if any, of the following benefits do you currently receive? r Supplemental Security Income r Social Security Disability r Both Printable PDF Version 
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