Neuropathy Disability Claim Evidence Checklist Form
Indicate and submit the evidence supporting your neuropathy disability claim.
Claimant Full Name
*
First Name
Last Name
Claim/Reference Number
*
Contact Email Address
*
example@example.com
Checklist of Evidence Provided
*
Medical diagnosis of neuropathy
Treatment records
Physician's statement
Functional capacity evaluation
Work impact documentation
Other relevant medical evidence
Briefly describe your neuropathy diagnosis and symptoms
*
Describe any treatments received for your neuropathy
Describe how neuropathy has impacted your ability to work
Upload supporting documents (medical records, statements, etc.)
*
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