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Federal Disability Form

ClearStep HR Consultant and Federal Disability Services, LLC client intake Form

Personal Information

Employment information for (federal disability retirement clients)

Employment Status:

Employment information for (federal disability retirement clients)

Employment Information for (federal disability retirement clients)

Medical Information ( Confidential)

List your primary condition(s):

Have you applied for FERS Disability before?
Yes
No
Have you applied for SSDI?
Yes
No

Employment Information

Have you requested a Reasonable Accommodation?
Yes
No

Goals & Concerns

Do you have any documentation relevant to your case?
Yes
No

Consent and Privacy Acknowledgment

I understand that ClearStep HR Consulting and Federal Disability Services, LLC will review the information I provide and may request additional details to assist me better. Submission of this form does not guarantee acceptance of services.


I consent to ClearStep HR Consulting and Federal Disability Services, LLC handling my information in accordance with HIPAA and the Privacy Act.

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Notice of privacy practices

We value your privacy. We comply with the Health Insurance Portability and Accountability Act (HIPAA) and the Privacy Act of 1974. Your medical records will be stored in encrypted, HIPAA-compliant systems. Access is limited to authorized staff assisting with your case. We do not share your information without your written consent, except as required by law.

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