entire clark cnty presentation materials packet for practitioners

7/30/2019 ENTIRE Clark Cnty Presentation Materials Packet for Practitioners

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Lisa R.J. Porter, Esq.Admitted in OR and WA

Melissa N. Kenney, Esq.Admitted in MD

Of Council: David B. LowryAdmitted in OR and AZ

The preparation of a Social Security Disability case requires the gathering of considerable information.

( ) Please obtain for me a printout from your pharmacy for all medicines.( ) Please send me a list of ALL of your medical, physical therapy, counseling, etc. appointments for

the past 24 months.( ) If you have not done so, please furnish me the names, addresses and telephone numbers of all

witnesses.( ) Please send me a copy of your disabled parking permit, or a copy of an application signed by your

Doctor.

( ) Please send me a copy of 30 days of blood sugar readings.( ) Please send me a copy of your hearing test results.( ) Please send me the name, address and claim number for your old Workers Compensation case.( ) Please send me a copy of all letters you have received from Social Security denying your disability

claim. This includes your current claim, as well as any earlier claims that were denied by the

Social Security Administration.

Whenever you answer questions or fill out a questionnaire for SSA, neither exaggerate or minimize your

condition. SSA will deny your claim easily if you tell them what you can do, or you do not explain that you

have problems doing these things. You want them to see the answers that reflect what you cannot do

and why, or what you do only with difficulty and why. Any SSA questionnaires you fill out should be

returned to ME and NOT to SSA. That way, I can make a copy and if you have said something unwise,

or which might confuse SSA, we can talk about it.

Thank you for your cooperation in this matter.

VERY IMPORTANT:

What is the name, address and telephone number of some one who DOES NOT LIVE WITH YOU, but

will ALWAYS know where your are?

Name:

Address:

City/State/Zip

Telephone:

Relationship:


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AUTHORIZATIONFORRELEASEOFINFORMATION

I authorize ____________________________________________________________________to disclose a copy of the health information described below regarding the following:

Name: _____________________ To: KP Law LLC

Attorneys At Law

SSN:___________________________ 16200 SW Pacific Hwy, Suite H-280DOB:__________________________ Portland, OR 97224(503) 245-6309

(503) 245-6725 FaxThe undersigned hereby authorizes attorney, Melissa N. Kenney, Lisa Porter, or any representative thereof, to obtain information, forthe purpose of obtaining Social Security Benefits.

PLEASE INITIAL ALL THE SPACES BELOW

_____ All Physician/Hospital/Clinic/Emergency/Urgent Care/Dental/Physical Therapy records (including lab, x-ray,diagnostic/consultative summaries), including protected records (if applicable) This authorization does not curtail the ability or inabilityto the condition of general healthcare upon its receipt.

_____ Billing Statements _____ Workers Compensation Records

PROTECTED OR SENSITIVE INFORMATION: I understand that the information used or disclosed pursuant to this authorization may besubject to re-disclosure and no longer be will protected under federal law. I also understand that federal or state law may restrict re-

disclosure of HIV/AIDS information, mental health information, genetic information and drug/alcohol diagnosis.

I authorize the release ofthe following protected or sensitive information:


_____ Drug/Alcohol diagnosis/treatment/or referral _______ Sexually transmitted diseases_____ Psychological and/or psychiatric treatment _______ AIDS/HIV test results, including RELATED_____ Genetic testing information high-risk behaviors


______ Police records _____ Adult & Family Services/Senior Disabled Services Records______ Employment records (Medical and Mental Health Treatment Records)______ Federal, state income records _____ Any and all School records and transcripts including all

counseling/psychological records______ I specifically consent to the FAXing of my records. All FAXed material will contain a confidentiality statement, however,understand confidentiality at the receiving end cannot always be guaranteed.

You do not need to sign this authorization. Refusal to sign the authorization will not adversely affect your ability to receive health careservices or reimbursement for services. The only circumstance when refusal to sign means you will not receive health care service is if thehealth care services are solely for the purpose of providing health information to someone else and the authorization is necessary to makethat disclosure. You may revoke this authorization, please send a written statement to KP Law LLC at the above address and state that you arerevoking this authorization.Unless revoked earlier, this consent will expire 180 days from the date of signing or shall remain in effect for the period reasonably needed tocomplete the request. This authorization is in compliance with HIPAA

PHOTOCOPIES OF THIS AUTHORIZATION ARE VALID AND MAY BE USED IN LIE OF THE ORIGINAL

Clients Name (Please print)___________________________________________

Dated:______________ Clients Signature __________________________________________________

If signed as parent or guardian, this authorization shall apply to the records of the above mentioned individual___________________________________ ___________________________________________________________________Name of Parent or Guardian of Client Parent or Guardians Signature

This is a true copy of the original authorization document. A true copy shall be deemed to be the same as the original thereof.

___________________________________________________________________9/09/2011 Forms/AUTHO Signature of Staff Person


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Social Security Administration Form Approved

Consent for Release of Information OMB No. 0960-0566

TO Social Security Administration

______________________ ___________ ___________________________

Name Date of Birth Social Security Number

I authorize the Social Security Administration to release information or records about me to:

Melissa N. Kenney 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224

Lisa R. Porter 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224

Nanette L Mitchell 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224

Leta Sanders 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224

Rahma Abdulaziz 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224

___X____ Social Security Number___X____ Identifying information (includes date and place of birth parents names)

___X____ Monthly Social Security benefit amount

___X____ Information about benefits/payments I received ______________ to _________________

___X____ Information aobut my Medicare claim/coverage from _____________to ________________

(specify)____________________________________________________________________

___X____ Medical records

_______ Record(s) from my file (specify)___________________________________________________

_____________________________________________________________________________

I am the individual to whom the information/record applies or that persons parent (if a minor) or legal

guardian. I declare under penalty of perjury that I have examined all of the information on this form and it is

true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or

misleading statement about a material fact in this information or causes someone else to do so, commits a

crime and may be sent to prison, or may face other penalties, or both.

Signature: _____________________________________________________________________________________

(show signature names and addresses of two people if signed by a mark)

Date:_________________________________ Relationship: ______________________________________

Form SSA-3288 (3-2005) EF (3-2005)


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DEPARTMENT OF HEALTH AND HUMAN SERVICE Form ApproSOCIAL SECURITY ADMINISTRATION/OFFICE OF HEARINGS AND APPEALS OMB No. 0960-0

REQUEST FOR REVIEW OF HEARING DECISION See Privacy Act(Take or mail original and all copies to your local Social Security office) Notice on Reverse

1. CLAIMANT 2. WAGE EARNER, IF DIFFERENT

3. SOCIAL SECURITY CLAIM NUMBER 4. SPOUSE'S NAME AND SOCIAL SECURITY NUMBER (Complete ONLY in Supplemental Security Income Cases)

5. I request that the Appeals Council review the Administrative Law Judge's action on the above claim because:

Claimant is Disabled.

ADDITIONAL EVIDENCE

If you have additional evidence, submit it with this request for review. If you need additional time to submit evidence or legal argument, you must request an extension of time in writing now. you request an extension of time, you should explain the reason(s) you are unable to submit the evidence or legal argument now. If you neither submit evidence or legal argument now nor withinany extension of time the Appeals Council grants, the Appeals Council will take its action based on the evidence of record.

IMPORTANT: Write your Social Security Claim Number on any letter or material you send us.

SIGNATURE BLOCKS: You should complete No. 6 and your representative (if any) should complete No. 7. If you are represented and your representative is not available to complete this form,you should also print his or her name, address, etc. in No. 7.

DATE

: ATTORNEY Q NON-ATTORNEY

6. CLAIMANT'S SIGNATURE 7. REPRESENTATIVE'S SIGNATURE

PRINT NAME

PRINT NAME

Melissa N Kenney Esq.

ADDRESS ADDRESS

16200 SW Pacific Hwy, Suite H-233

(CITY, STATE, ZIP CODE) (CITY, STATE, ZIP CODE)

Portland OR 97224TELEPHONE NUMBER (INCLUDE AREA CODE) TELEPHONE NUMBER (INCLUDE AREA CODE)

503-245-6309

THE SOCIAL SECURITY ADMINISTRATION STAFF WILL COMPLETE THIS PART

8. Request received for the Social Security Administration on by:

(Title) (Address)Servicing FO Code PC Code

9 Is the request for review received within 65 days of the ALJ'S Decision/Dismissal Yes G No G

10. If no checked: (1) attach claimant's explanation for delay; and (2) attach copy of appointment notice, letter or other pertinent material or information in the Social Security Office.

11. Check one: Q Initial Entitlement Q Termination or other

APPEALS COUNCILOFFICE OF HEARINGS AND APPEALS, SSA5107 Leesburg PikeFALLS CHURCH, VA 22041-3255

12. Check all claim types that apply: Q Retirement or survivors (RSI) Q Disability - Worker (DIWC) Q Disability - Widow(er) (DIWW) Q Disability - Child (DIWC) Q SSI Aged (SSIA) Q SSI Blind (SSIB) Q SSI Disability (SSID) Q Health Insurance - Part A (HIA) Q Health Insurance - Part B (HIB) Q Other -- Specify:

Form HA-520-U5 (3-94)Destroy old stock CLAIMS FOLDER


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16200SWPacificHwy,Ste.H233*PortlandOR97224*5032456309office/5032962632*www.kplawllc.com*[email protected]

Lisa R.J.Porter,EsqAdmittedinORandWA

MelissaN.Kenney,EsqAdmittedinMD

OfCouncil: DavidB.LowryAdmittedinORandAZ

Certified Mail

Appeals Council

Office of Disability Adjudication and Review

5107 Leesburg Pike

Falls Church, VA 22041

RE:S.S.N.:

Dear Appeals Council:

On behalf of the above claimant, we request a review of the decisions of ALJ * dated *.

I request a copy of the tapes of the hearings and all exhibits. I request 45 days from receipt thereof inwhich to submit additional evidence and/or argument.

Thank you.

Yours truly,

Melissa N Kenney, Esq.

MNK/nm

Enclosure(s)

c: file Claim 2

cc:

(Client Here)

cc:

(Local SSA Branch Here)


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Case Analysis Form

Name: __________________________________________________ DOB _________________

Theory: __________________________________________________________________________

__________________________________________________________________________

Med-Voc Rule__________ Listings ___________ Alleged Onset:______________ DLI:_____________

Issues: __________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

ATTORNEY'S RANKING OF IMPAIRMENTS ASSOCIATED SYMPTOMS

1. 1.

2. 2.

3. 3.

4. 4.

5. 5.

Date Last Worked: ____________ Age today: ________ Age at onset: ________

Past 15 years or 15 years before date last insured, if earlier. * Enter C for customary, E for easiest job.

Dates Occupation StrengthLevel

SkillLevel

DOT No. C/E*

Unable to do easiest job because: ___________________________________________________________

Limited to: less than sedentary alt sit/stand sedentary light medium

Mental limitations: ________________________________ Work skills: _________________________

Highest Grade Completed: _______ Vocational Training: ______________________________________

Check here if abilities appear less than level of schooling would indicate.

Summary of Physical Residual Functional Capacity

_________________________________ says that s/he can walk about _____ blocks before stopping.

S/he can sit for about _____ minutes at one time and stand for about _____ minutes at one time.

Out of an 8-hour working day, s/he says s/he can sit for a total of hours and stand/walk for a total of

hours.

S/he needs to walk around approximately every _____ minutes for about _____ minutes.

S/he needs a job that permits shifting positions at will.


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Becauseof

muscle weakness pain/ paresthesias, numbness _________________

chronic fatigue adverse effects of medication _________________

s/he may need to take unscheduled breaks [ to lie down] during an 8-hour working day. S/he expects this tohappen ______________________________; and s/he may need to rest ___________ minutes (on average)before returning to work.

If s/he had a sedentary job, because of ___________________________ s/he says s/he would need to elevatehis/her legs about _____% of the time during an 8-hour working day. S/he needs to elevate his/her legs about

hip /

heart ______ high.

S/he needs a cane to walk because of

imbalance pain weakness dizziness

insecurity ________________________________________

S/he can occasionally lift and carry _____ lbs. and frequently lift and carry _____ lbs.

S/he says that because of

pain/ paresthesias motor loss sensory loss/ numbness

muscle weakness swelling side effects of medication

limitation of motion _______________________________________

s/he has significant limitations in reaching, handling, and fingering.

S/he can use her/his left hand for S/he can use her/his right hand for

grasping _____% of the time, grasping _____% of the time,

fingering _____% of the time, fingering _____% of the time, and

reaching overhead _____% of the time, and reaching overhead _____% of the time, and

reaching in front of body _____% of the time. reaching in front of body _____% of the time.

S/he says that s/he can

never rarely occasionally frequently

twist,

stoop (bend),

crouch/ squat,

climb ladders, and

climb stairs.


never rarely occasionally frequently

look down (sustained flexion of neck), turn head right or left,

look up, and

hold head in static position.

S/he says that s/he has the following environmental limitations:

__________________________________________________________________________________

__________________________________________________________________________________

- 2 -


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- 3 -

S/he says that her/his symptoms (often) (frequently) (constantly) are severe enough to interfere withattention and concentration so that s/he would be off task at work 5% / 10% / 15% / 20% / 25% or more / of the time.

S/he says that as a result of his/her impairments s/he has a (moderate) (marked) (severe) limitation in dealingwith work stress.

Because of bad days, s/he says that if s/he had a full-time job s/he expects that s/he would miss workabout/ more than _____ times a month.

VISION


never rarely occasionally frequently constantly

utilize near acuity,

utilize far acuity, and

utilize depth perception.

S/he is incapable of avoiding ordinary hazards in the workplace, such as boxes on the floor, doors ajar,

approaching people or vehicles.

S/he has difficulty walking up or down stairs because of his/her vision.

S/he says s/he cannot work with small objects such as those involved in doing sedentary work.

S/he can/ cannot work with large objects.

Other: ____________________________________________________________________________

__________________________________________________________________________________

NOW

DOCTORS TO GET RFCOPINIONS FROM

TYPE OFRFC FORM

OTHER RECORDS THAT SSAMAY NOT HAVE OBTAINED

1. 1.

2. 2.

3. 3.

4. 4.

LONG TERM DISABILITY CARRIER OTHER RECORDS NEEDED

Name: SS file from local officeWork records - employer:________________

Address: Vocational rehabilitation records L.T.D. carrier records

School records Driving record

Other:_________________________________ Other:_________________________________


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- 4 -

Flag to work up for possible on-the-record decision. Impression: __________________

Request postponement of hearing scheduled for _________ with ALJ ______________

OTHER THINGS TO DO______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

THINGS OUR CLIENT WILL SEND US______________________________________________________________________________________

______________________________________________________________________________________

1-252/04175.1


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Lisa R.J. Porter, Esq.

Admitted in OR and WA

Melissa N. Kenney, Esq.

Admitted in MD

Of Counsel: David B. Lowry, Esq.Admitted in OR and AZ

[DATE]

[CLIENT NAME AND ADDRESS]

RE: Your Social Security Claim

Dear :

We have filed an appeal on your behalf because we received a notice that you were denied benefits.

We have to submit the enclosed form SSA-3441 with this appeal. The Social Security office will take no

action until the enclosed form is returned to our office and forwarded to the property SSA office. If you

have any questions, please call us immediately. PLEASE NOTE this needs to be done as soon as

possible. We have enclosed a self-addressed stamped envelope for your use to return this form to us.

Please do not return the instruction and privacy sheet. You may find it easier to list your prescription

medications by going to your pharmacy and asking for a printout of your prescription history for the last

6 months.

***HELPFUL HINT: I encourage you to make a copy of this form before you return it to us so

you can use it for an information reference in the future. You may have to complete this form again to

updated your file. We have been told that Social Security will NOT move your claim forward withoutthis completed form*****

We may have to include a SSA-827 (if this form is needed it will be enclosed). You need to SIGN AND

DATE.

Please use DARK INK when completing the questionnaire. Please DO NOT use pencil.

If you have any questions, dont hesitate to give us a call.

Yours truly,

Nanette L. Mitchell, Paralegal to

KP Law LLC,

Melissa N. Kenney and Lisa R. Porter, Attorneys

/nm

Enclosure(s)


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16200 SW Pacific Hwy, Ste. H-233* Portland OR 97224 *503-245-6309 office / 503-296-2632 * www.kplaw-llc.com * [email protected]

Lisa R.J. Porter, EsqAdmitted in OR and WA

Melissa N. Kenney, EsqAdmitted in MD


RE: Your Social Security Claim

Dear :

We are sending you forms to complete, sign and return to our office. If you are receiving this letter and packet, we have

reason to believe that you are responsible and will return the materials as soon as possible. We are sure that this will beeasier and less expensive than a visit to our office. This packet should include the following. If something is missing,

please contact our office. Please use dark (Black or Dark Blue) ink when completing the forms. Please do NOT use

pencil.

FORM NEEDS

* SSA-1696 Appointment of Rep. (Signature where indicated)

* 2 "Fee Agreement" forms. (Signature where indicated)

* SSA-3288 Consent for Release... (Name; Date of Birth; SS#; Signature; Date)

* SSA-827 Authorization to Disclose (Signature, date)

* Authorizations for Release... (Initial ALL highlighted blanks; Sign; Do NOT date)

* Alternate Contact (Name of someone who knows how we can reach you in an emergency).

Thank you for your time and attention to this matter. If you have any questions, please do not hesitate to contact this

office. We will be happy to answer your questions so we do not have to return the forms to you for correction or

completion. Please contact our office three (3) days after you return the documents back to our office. At that time, we

will schedule you for an appointment with an attorney in our office.

Finally, if you have received a denial, please send us copies of all denials that you have received. This can be very

important to our course of action.

Yours truly,

, Paralegal to

Melissa Kenney and Lisa Porter, Attorneys

/nm

Enclosure(s)


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DISABILITY REPORT - APPEAL - Form SSA-3441-BK

READ ALL OF THIS INFORMATION BEFORE YOU BEGIN

COMPLETING THIS FORM

HOW TO COMPLETE THIS FORM

ABOUT YOUR MEDICAL RECORDS

We will use the information that you give us on this form to update your disability report

information for your appeal. We will use the form to update your disability information since

you last completed a disability report. Please complete as much of the form as you can. If

you need help, your interviewer will help you finish it. If you have an appointment for aninterview by telephone, have the form ready to discuss with us when we call you. If you have

an appointment for an interview in our office, bring the completed form with you or mail itahead of time, if you were told to do so. If you have access to the Internet, you may access the

Disability Report Form - Appeal instructions at http://www.ssa.gov/online/ssa-3441.html.

If you are filling out the form for someone else, please provide information about him or her.

When a question refers to "you," "your," or the "Disabled Person," it refers to the person who

is applying for or has been entitled to disability benefits.

Print or write clearly.

DO OT LEAVE ASWERS BLAK. If you do not know the answers, or the answeris "none" or "does not apply," please write: "don't know," or "none," or "does not apply."

I SECTIO 3, PUT IFORMATIO O OLY OEDOCTOR/HMO/THERAPIST/OTHER/HOSPITAL/CLIIC I EACH SPACE.

Each address should include a ZIP code. Each telephone number should include an area code.

DO OT ASK A DOCTOR OR HOSPITAL TO COMPLETE THIS FORM.However, you can get help from other people, like a friend or family member.

Be sure to explain an answer if the question asks for an explanation, or if you want to giveadditional information.

If you need more space to answer any questions or want to tell us more about an answer,please use Section 10 - REMARKS on Page 7, and show the number of the question being

answered.

If you have any medical records or copies of prescriptions at home, send them to our office with

your completed form or, if you are having an interview in our office, bring them and anymedicine containers with you. If you need the records back, tell us and we will photocopy them

and return them to you.

YOU DO OT EED TO ASK DOCTORS OR HOSPITALS FOR AY MEDICAL

RECORDS THAT YOU DO OT ALREADY HAVE. With your permission, we will do that

for you. The information we ask for on this form tells us to whom we should send a request for

medical and other records. If you cannot remember the names and addresses of your medicalsources, you may be able to get that information from the telephone book, medical bills,

prescriptions, or prescription containers.


14/56

AFTER COMPLETIG THIS FORM, REMOVE THIS SHEET AD KEEP IT

FOR YOUR RECORDS.

We are authorized to collect the information on this form under sections 205(a) and (b), 223(d),

and 1631(e)(1) of the Social Security Act. We will use the information you provide on this form tomake a decision on your claim or case. Your response to this request is voluntary. However, failure

to provide all or part of the information could prevent us from making an accurate and timely

decision on your claim or case.

We rarely use the information you supply for any purpose other than for determining your living

arrangements. However, we may use it for the administration and integrity of Social Securityprograms. We may also disclose information to another person or to another agency in accordance

with approved routine uses, which include but are not limited to the following: (1) to enable a

third party or an agency to assist Social Security in establishing rights to Special VeteransBenefits; (2) to comply with Federal laws requiring the release of information from Social

Security records (e.g., to the Department of Veterans Affairs); (3) to make determinations for

eligibility in similar health and income maintenance programs at the Federal, State, and local level;

and (4) to facilitate statistical research, audit, or investigative activities necessary to assure theintegrity of Social Security programs.

We may also use the information you provide in computer matching programs. Matching programscompare our records with records kept by other Federal, State, or local government agencies.

Information from these matching programs can be used to establish or verify a person's eligibility

for Federally-funded or administered benefit programs and for repayment of payments ordelinquent debts under these programs.

Additional information regarding this form, routine uses of information, and our programs and

systems, is available on-line at www.socialsecurity.gov or at any local Social Security office.

The Privacy Act

This information collection meets the requirements of 44 U.S.C. 3507, as amended by

Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions

unless we display a valid Office of Management and Budget control number. We estimate that itwill take about 45 minutes to read the instructions, gather the facts, and answer the questions.

SED OR BRIG THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY

OFFICE. The office is listed under U. S. Government agencies in your telephone directory

or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send

comments on our time estimate above to: SSA, 6401 Security Boulevard, Baltimore, MD

21235-6401. Send only comments relating to our time estimate to this address, not thecompleted form.

The Paperwork Reduction Act


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Request for Review by Federal

Request for ALJ Hearing

Reconsideration

Reconsideration for Disability Cessation

- -

- -

C. DAYTIME TELEPHONE NUMBER (If you do not have a number where we can reach you, give us a

daytime number where we can leave a message.)

D. Give the name of a friend or relative that we can contact (other than your doctors) whoknows about your illnesses, injuries, or conditions and can help you with your claim orcase.

(Number, Street, Apt. No.(If any), P.O. Box, or Rural Route)

RELATIONSHIP

City State

ZIP

-

NumberArea Code

DAYTIMEPHONE

NAME

ADDRESS

NoneYour Number Message Number

Area Code Number

( ) -

SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON

B. SOCIAL SECURITY NUMBERA. NAME (First, Middle Initial, Last)

SOCIAL SECURITY ADMINISTRATIONForm ApprovedOMB No. 0960-0144

DISABILITY REPORT - APPEAL

( ) -

Date of LastDisability Report

Number Holder

Related SSN

Has there been any change (for better or worse) in your illnesses, injuries, or conditionssince you last completed a disability report?

A.

SECTION 2 - INFORMATION ABOUT YOUR ILLNESSES, INJURIES, OR CONDITIONS

PAGE 1Form SSA-3441-BK (08-2010) ef (08-2010) Destroy Prior Editions

Approximate date thechanges occurred:

Month Day Year

B.


Month Day Year

Yes No

If "Yes," please describe in detail:


For SSA Use OnlyDo not write in this box.

NoYes

Do you have any new physical or mental limitations as a result of your illnesses, injuries,or conditions since you last completed a disability report?

Reviewing Official

Individual

is filing:


16/56

Since you last completed a disability report, have you seen or will you see a

doctor/hospital/clinic or anyone else for emotional or mental problems that limit your

abilit to work?

List other names you have used on your medical records.

Since you last completed a disability report, have you seen or will you see a

doctor/hospital/clinic or anyone else for the illnesses, injuries, or conditions that limit

your ability to work?


Do you have any new illnesses, injuries, or conditions since you last completed adisability report? NoYes

A.

B.

C.

NOYES

YES NO

C.

If you answered "NO" to both A and B, go to Section 4 - MEDICATIONS.

SECTION 3 - INFORMATION ABOUT YOUR MEDICAL RECORDS


Month Day Year

If you need more space, use Section 10 - REMARKS.

PHONE

STATE ZIP

NAME

STREET ADDRESS FIRST VISIT

LAST VISITCITY

PATIENT ID # (If known) NEXT APPOINTMENT

Tell us who may have medical records or other information about your illnesses, injuries, or

conditions since you last completed a disability report.

D. List each DOCTOR/HMO/THERAPIST/OTHER. Include yournext appointment.

DATES1.

-

( ) -

Area Code Phone Number

REASONS FOR VISITS

WHAT TREATMENT DID YOU RECEIVE?

PAGE 2Form SSA-3441-BK (08-2010) ef (08-2010)


17/56

PHONE

STATE ZIP

NAME


LAST VISITCITY

PATIENT ID # (If known) NEXT APPOINTMENT

DATES2.

-

( ) -Area Code Phone Number

REASONS FOR VISITS

WHAT TREATMENT DID YOU RECEIVE?

EMERGENCYROOM VISITS

E. List each HOSPITAL/CLINIC. Include ournext a ointment.

HOSPITAL/CLINIC TYPE OF VISIT

NAME

STREET ADDRESS

PHONE

DATES

CITY ZIP

-

Phone NumberArea Code

( ) -

INPATIENTSTAYS

(Stayed at least overnight)

OUTPATIENTVISITS

(Sent home same day)

DATE IN

DATE FIRST VISIT DATE LAST VISIT

DATE OUT

DATES OF VISITS

Next appointment Your hospital/clinic number

Reasons for visits

What treatment did you receive?

What doctors do you see at this hospital/clinic on a regular basis?

PAGE 3

STATE

Form SSA-3441-BK (08-2010) ef (08-2010)




18/56

Are you currently taking any medications for your illnesses, injuries or conditions?

If "YES," please tell us the following: (Look at your medicine containers, if necessary.)

F. Since you last completed a disability report, does anyone else have medical records

or information about your illnesses, injuries, or conditions (for example, Workers'

Compensation, insurance companies, prisons, attorneys, or welfare agency), or are you

scheduled to see anyone else? YES NO

CLAIM NUMBER (if any)

REASONS FOR VISITS

PHONE

STATE ZIP

NAME


LAST VISITCITY

NEXT APPOINTMENT

DATES

-

( ) -

Area Code Phone Number

If "YES," complete information below:

SECTION 4 - MEDICATIONS

PAGE 4

NOYES

NAME OF MEDICINEIF PRESCRIBED, GIVE

NAME OF DOCTOR REASON FOR MEDICINESIDE EFFECTS YOU

HAVE

Form SSA-3441-BK (08-2010) ef (08-2010)




19/56

X-RAY -- Name of body part

Since you last completed a disability report, have you had any medical tests for illnesses,injuries, or conditions or do you have any such tests scheduled?If "YES," please tell us the following: (Give approximate dates, if necessary.)

SECTION 5 - TESTS

KIND OF TEST

WHEN WAS/WILL

TEST BE DONE?

(Month, day, year)

WHERE DONE?

(Name of Facility)

WHO SENT YOU FOR

THIS TEST?

EKG (HEART TEST)

TREADMILL (EXERCISE TEST)

CARDIAC CATHETERIZATION

BIOPSY -- Name of body part

HEARING TEST

SPEECH/LANGUAGE TEST

VISION TEST

IQ TESTING

EEG (BRAIN WAVE TEST)

HIV TEST

BLOOD TEST (NOT HIV)

BREATHING TEST

MRI/CT SCAN -- Name of bodypart


NOYES

PAGE 5

SECTION 7 - INFORMATION ABOUT YOUR ACTIVITIES

If"YES," you will be asked to give details on a separate form.

YES NOHave you worked since ou last completed a disability report?

SECTION 6 - UPDATED WORK INFORMATION

How do your illnesses, injuries, or conditions affect your ability to care for your personal

needs?

A.

Form SSA-3441-BK (08-2010) ef (08-2010)


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an individual work plan with an employment network under the Ticket to Work Program;

any program providing vocational rehabilitation, employment services, or other support services to helpyou go to work?


B. What changes have occurred in your daily activities since you last completed a

disabilit re ort?

Have you completed any type ofspecial job training, trade or vocational school since you

last completed a disabilit report?

SECTION 8 - EDUCATION/TRAINING INFORMATION

If "YES," describe what type:

YES NO

Approximate date completed:

PAGE 6

SECTION 9 - VOCATIONAL REHABILITATION, EMPLOYMENT, OTHER SUPPORT

SERVICES INFORMATION, OR INDIVIDUALIZED EDUCATION PROGRAM

NOYES

If "YES," complete the following information:

-

City State ZIP

(Number, Street, Apt. No.(if any), P.O. Box, or Rural Route)

Area Code Number

TO

(IQ, vision, physicals, hearing, workshops, classes, etc.)

TYPE OF SERVICES,TESTS, OR EVALUATIONSPERFORMED

NAME OF ORGANIZATION OR SCHOOL

NAME OF COUNSELOR OR INSTRUCTOR

ADDRESS

DAYTIME PHONE NUMBER

DATES SEEN

( ) -

If none, show "NONE."

Since you last completed a disability report, have you participated, or are you participating

an individualized plan for employment with a vocational rehabilitation agency or any other organization;

a Plan to Achieve Self-Support;

an individualized education program through an educational institution (if a student age 18-21); or

Form SSA-3441-BK (08-2010) ef (08-2010)


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SECTION 10 - REMARKS

Use this section for any additional information you did not show in earlier parts of this

form. When you are finished with this section (or if you don't have anything to add), be

sure to go to the next page and complete the blocks there.

PAGE 7Form SSA-3441-BK (08-2010) ef (08-2010)


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SECTION 10 - REMARKS

PAGE 8

Date Form Completed (Month, day, year)

-

ZIPState

Name of person completing this form if other than the disabledperson (Please print)

City

E-Mail Address of person completing this form (optional)

Address (Number and street)

If the person completing this form is other than the disabled person or the person identified in Section 1. Item D.,please complete the following information.

Relationship to Disabled Person Daytime Telephone Number

( ) -

Form SSA-3441-BK (08-2010) ef (08-2010)


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16200 SW Pacific Hwy, Ste. H-233* Portland OR 97224 *503-245-6309 office /F: 503-296-2632 * www.kplaw-llc.com * [email protected]

Lisa R.J. Porter, Esq


Melissa N. Kenney, Esq

Admitted in MD

Of Counsel: David B. Lowry, Esq

Admitted in OR and AZ

DATE

CLIENT NAME AND ADDRESS

RE: Hearing Scheduled

Dear ,

Congratulations, we have a hearing scheduled for you on: DATE at TIME.

To prepare we would like you to contact any doctors/hospitals/clinics that have been treating you and be sure to

request those records as soon as possible. Your medical records are the cornerstone of your disability claim so youneed to get them to us well in advance of your hearing. Please have them faxed, or put on CD to be brought in to us or

just mail them to us. You will be receiving a letter asking you to acknowledge this hearing date and time. It is important

that you return this as soon as possible. You do not need to send us a copy of this acknowledgement; it is a standard

practice of ODAR.

It will be important for you to bring at least one person with you to the hearing as a potential witness. You will need to

have current identification to get into the building and to your hearing. Please BE EARLY as this security measure can

take a few minutes. You will be meeting with your attorney at least 30 minutes BEFORE the hearing, so they can prepar

you. The hearings are kept relatively casual as everyone that attends them is also applying for disability and they

understand you may have special needs. The Administrative Law Judges (ALJs ) try to keep the hearings to no more

than one hour in length.

The Attorney will be calling you to discuss your hearing with you before your hearing. If you have a new address or

phone number as contact, it is important you let us know that, so we can be in good communication.

Thanking you in advance for your time and we look forward to a successful outcome.

Yours Truly,

Nanette L. Mitchell, Paralegal for

Melissa N. Kenney, Attorney and Lisa R. Porter, Attorney

KP Law LLC

/nm


24/56

[THIS IS TAKEN DIRECTLY FROM JAMES PUBLISHINGS WEBSITE www.ssas.com AND IS

FREE TO USE]

Intake Action Sheet

Name: ________________________

Date: __________________

[ ] Letter to Local Office:

[ ] New Application Letter

[ ] Cover Letter (in a pending case) With:

[ ] Request for Reconsideration

[ ] Request for Hearing

[ ] Disability ReportAppeal

[ ] Signed Releases

[ ] Appointment of Representative Form

[ ] Attorney or Client Fee Agreement

[ ] Direct Payment of Authorized Fees Form SSA-1695

[ ] cc to Office of Disability Adjudication and Review

[ ] cc to Client With Fee Agreement

[ ] cc to Disability Determination Bureau With Enclosures

[ ] Re-Open Prior Application

[ ] Request Local Hearing

[ ] Appealing Onset Date Only

[ ] Opening Letter to Client

[ ] Thank You Letter to Referral Source

[ ] Letter to Client With Diary:

[ ] Seizure Diary

[ ] Headache Diary

[ ] MS Diary

[ ] Other: ____________________


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[ ] Letter to Disability Determination Bureau: Now Send in 30 Days

[ ] Request Medical CE

[ ] Request Psych CE

[ ] Request State Agency RFCs (both physical and mental)

[ ] Request State Agency Electronic Worksheet and/or Rationale for Denying Claim

[ ] Supply Additional Medical Records

a.

b.

c.

[ ] Supply Photos

[ ] Other: __________________

[ ] Letter to Local Office Requesting eDib File (CD)

[ ] Letter to Office of Disability Adjudication and Review

[ ] Request DISCO DIB Earnings Record

[ ] National Directory New Hire, Wage and Unemployment Report for the Following Years:

__________________________

[ ] Detailed Earning Report: _____________ to Present

[ ] Other:

[ ] Letter to Former Employer (__________________) Requesting Confirmation of Last Day of Work

[ ] Letter to Former Employer Requesting Personnel File (specify portion or specific documents)

[ ] Letter to Medical Providers Requesting Records:

a. covering

b. covering

c. covering

d. covering

[ ] Letter to Vocational Rehabilitation Agency Requesting Copy of File

[ ] Run Client Through Legal Database


26/56

Social Security AdministrationPlease read the instructions before completing this form.

Form ApprovedOMB No. 0960-0527

Name (Claimant) (Print or Type) Social Security Number

Wage Earner (If Different) Social Security Number

Part I APPOINTMENT OF REPRESENTATIVE

I appoint this person, Melissa N. Kenney, 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224(Name and Address)

to act as my representative in connection with my claim(s) or asserted right(s) under:

XTitle II(RSDI)

X Title XVI(SSI)

Title XVIII(Medicare Coverage)

Title VIII(SVB)

This person may, entirely in my place, make any request or give any notice; give or draw out evidence orinformation; get information; and receive any notice in connection with my pending claim(s) or asserted right(s).

X I authorize the Social Security Administration to release information about my pending claim(s) or asserted right(s) to designatedassociates who perform administrative duties (e.g. clerks), partners, and/or parties under contractual arrangements (e.g. copyingservices) for or with my representative.

X I appoint, or I now have, more than one representative. My main representative is

Melissa N. Kenney .(Name of Principal Representative)

Signature (Claimant) Address

Telephone Number (with Area Code) Fax Number (with Area Code) Date

Part II ACCEPTANCE OF APPOINTMENT

I, Melissa N. Kenney , hereby accept the above appointment. I certify that I

have not been suspended or prohibited from practice before the Social Security Administration; that I am notdisqualified from representing the claimant as a current or former officer or employee of the United States;and that I will not charge or collect any fee for the representation, even if a third party will pay the fee, unless ithas been approved in accordance with the laws and rules referred to on the reverse side of therepresentative's copy of this form. If I decide not to charge or collect a fee for the representation, I will notifythe Social Security Administration. (Completion of Part III satisfies this requirement.)

Check one: X I am an attorney. I am a non-attorney eligible for direct payment under SSA law. I am a non-attorney not eligible for direct payment.

I am now or have previously been disbarred or suspended from a court or bar to which I was previously admitted to practice as an attorney. Yes x NoI am now or have previously been disqualified from participating in or appearing before a Federal program or agency. Yes x No

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements orforms, and it is true and correct to the best of my knowledge.

Signature (Representative) Address16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224

Telephone Number (with Area Code)(503)245-6309

Fax Number (with Area Code)(503)245-6725

Date

Part III FEE ARRANGEMENT(Select an option, sign and date this section.)x Charging a fee and requesting direct payment of the fee from withheld past-due benefits.(SSA must authorize the fee unless aregulatory exception applies. Charging a fee but waiving direct payment of the fee from withheld past-due benefits --I do not qualify for or do not request direct

payment. (SSA must authorize the fee unless a regulatory exception applies.) Waiving fees and expenses from the claimant and any auxiliary beneficiaries --By checking this block I certify that my fee will be paidby a third-party, and that the claimant and any auxiliary beneficiaries are free of all liability, directly or indirectly, in whole or in part, to pay anyfee or expenses to me or anyone as a result of their claim(s) or asserted right(s). (SSA does not need to authorize the fee if a third-partyentity or a government agency will pay from its funds the fee and any expenses for this appointment. Do not check this block if a third-partyindividual will pay the fee.) Waiving fees from any source --I am waiving my right to charge and collect any fee, under sections 206 and 1631(d)(2) of the SocialSecurity Act. I release my client and any auxiliary beneficiaries from any obligations, contractual or otherwise, which may be owed to me forservices provided in connection with their claim(s) or asserted right(s).

Signature (Representative) Date

Form SSA-1696-U4 (03-2011) ef (03-2011)Destroy Prior Editions


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TWO-TIERED FEE AGREEMENT - SOCIAL SECURITY DISABILITY / SSI

ATTORNEY FEE: I employ Lisa R. Porter and/or Melissa N. Kenney to represent me before the Social SecurityAdministration (SSA) in my disability case. If I win at any administrative level through the first administrative lawjudge (ALJ) decision after the date of this agreement, I agree that the attorney fee will be the lesser of twenty-fivepercent (25%) of all past-due benefits awarded to the claimant and all auxiliary beneficiaries under this claim, or thedollar amount established pursuant to 42 U.S.C. 406(a)(2)(A), which is currently $6000, but may be increased fromtime to time by the Commissioner of Social Security. The fee level in effect when my claim is decided is theamount that will apply for my case. I understand that my attorney has the right to seek administrative review to

increase the amount of the fee set under the preceding sentence of this agreement; but if that happens, my attorneywill not ask for a fee of more than 25% of total back benefits awarded in my case. If the first ALJ decision after thedate of this agreement is a denial and my attorney agrees to appeal and I win my case later, the fee will be twenty-five percent (25%) of all back benefits awarded in my case. If I receive both social security disability and SSIbenefits, I understand that my total fee will not be more than 25% of all past-due benefits, or no more than the limitset by 42 U.S.C. 406(a)(2)(A), if the limit applies. I understand that if I do not win benefits, then the attorneys getno fee.

SCOPE OF REPRESENTATION: I have employed my attorneys to represent me in my Social Security disabilityand/or SSI claim. I understand that my attorneys do not represent me in any other public or private claim related tomy disability, or with any other government agency or any insurance company unless separate arrangements,including a separate written contract, have been made for representation on any other claim.

PAYMENT OF ATTORNEYS FEE: I understand that SSA will hold out 25% of past-due benefits and pay myattorneys for their work on my case unless my attorneys waive withholding and direct payment. If the attorneys

waive withholding and direct payment or if SSA fails to withhold attorney fees, I will pay my attorneys promptlyfrom the back benefits I receive.

I WILL PAY EXPENSES: In addition to fees, I agree to pay my attorneys for reasonable expenses that they pay inmy case. These may include medical records and reports, photocopying, travel expenses, transcript preparation, andthe like. I will get a bill for expenses that show how and when my attorneys spent the money. In a case in which Iget benefits, I agree to pay my attorneys back for these expenses as soon as I get a check for back benefits. I agreeto pay expenses whether we win or lose.

USE OF SOCIAL SECURITY NUMBERS: I understand that in order to represent me my attorney(s) are oftenrequired to include my full, unredacted social security numbers on various documents in the course of exchanginginformation relative to my Social Security claim(s) including those filed with the Social Security Administration,and that these documents are sometimes filed through the mail. I further understand that while I do not have toconsent to allow this practice, which, without my consent, may be a violation of Oregon law, as I also do not have to

execute this agreement at all, I want my attorney(s) to be able to fully represent me on these matters. Being fullyinformed, I hereby give my complete and unreserved consent to such social security number disclosure by myattorney(s) whenever in their sole judgment it is required or desirable.

I HAVE NOT BEEN PROMISED THAT I WILL WIN: My attorneys promised that they will do their best tohelp me. They did not promise me that I will win.

I accept and approve this agreement:Date:__________________________

____________________________________ _______________________________________Lisa R. Porter, Esq. Signature of Claimant

Name:

____________________________________ SSN.______________________________Melissa N. Kenney, Esq.


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MEDICAL RECORDS AGREEMENT

Medical providers, e.g., Doctors, hospitals, clinics, counseling agencies, mental and physical

therapy agencies, all charge lawyers top dollar for copies of medical records and these high

costs then get passed on to clients, including you. Their patients - you - are usually able to

obtain copies of these records at lower cost or free. Therefore, as one of our clients, you agreeas follows:

1. I will obtain, and send promptly to my lawyers, copies of all medical records I cause to be

generated during the life of my case.

2. I will obtain, and send promptly to my lawyers, copies of all important diagnostic test

results. These include blood chemistry work-ups; X-Rays; CAT scans; MRI scans; Pulmonary

Function tests; sleep studies; anything that is a test done to help a medical provider understand

what is or is not a problem for me.

3. I will obtain, and send promptly to my lawyers copies of all EMERGENCY ROOM records

that I may cause to exist by virtue of requesting help at a Hospital Emergency room or a facility

often called an Emergi-Center. I understand that Emergency Room records have to be ordered

separately from other hospital records, as hospitals usually keep these records separately.

4. I will obtain, and send promptly to my lawyers, copies of any medical records that pre-date

my application for Social Security Disability by one year or more, that will establish a diagnosis

and outlook for medical conditions, including mental health, which continue to represent a more

than minimal effect upon my ability to get around and do things, like work. For this purpose,

work includes my past work, as well as other work Social Security might claim that I can do.

Such work includes jobs where I would sit for at least 6 hours out of an 8 hour day; jobs where I

would stand and/or walk for at least 6 hours out of an 8 hour day.

It is never a good idea to tell a medical provider that a lawyer or a legal case of some

kind is involved. If you do, they likely will tell you that you cannot have the records, your

lawyer has to order them. This is done so that they can charge me top dollar. Keep this in

mind. Because you will end up paying top dollar.

Accepted by:_________________________

Lisa R. Porter, Esq.

Signature:___________________________

Name:

SSN:

Date:


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Medical Provider Contact Information

Your attorney requests you to obtain complete treatment records from all healthcareproviders, physical and mental. It is essential that you provide contact information for allProviders. We cannot win your case without this information! Becomplete!

Name:______________________ SSN:_____________________

Submit Contact Information ForallHealthcare Providers:

PROVIDER: PHYSICAL MENTAL

Clinic Name: _________________________ __________________________

Street Address 1: _________________________ __________________________

Street Address 2: _________________________ __________________________

City/State : _________________________ __________________________

Zip Code : _________________________ __________________________

Doctor=s Name: _________________________ __________________________

Clinic Name: _________________________ __________________________

Street Address 1: _________________________ __________________________

Street Address 2: _________________________ __________________________

City/State : _________________________ __________________________

Zip Code : _________________________ __________________________

Doctor=s Name: _________________________ __________________________


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Former Employer Contact Information

Your attorney has requested that we obtain information from previous former

employer(s). Please return this form with the following former employer

information:

Name:________________________ SSN:______________________

Submit contact information for the last _____ employer(s).

Employer: _____________________________

Street Address 1: _____________________________

Street Address 2: _____________________________

City/State: _____________________________

Zip Code: _____________________________

Phone: _____________________________

Supervisor: _____________________________

Employer: _____________________________

Street Address 1: _____________________________

Street Address 2: _____________________________

City/State: _____________________________

Zip Code: _____________________________

Phone: _____________________________

Supervisor: _____________________________

Upon receipt from you, we will request that an employer questionnaire

be completed by the indicated contact(s).


31/56

AUTHORIZATION TO DISCLOSE INFORMATION TO

KP Law LLC

REGARDING

NAME:______________________ SSN: _______________BIRTHDATE:______________

I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange)

OF WHAT: All my contact information. This includes specific permission to release:

1. All records and other information regarding my recent contact information including and

not limited to:

Information specifically to include any and all contact information maintained by the

State in connection with the administration of any benefits program or any other records

the State may have regarding my location, or which might lead to discerning my

location. This authorization applies to physical or postal addresses, phone numbers, e-mail addresses, and contact information via all private and public parties who may know

how to locate me.

FROM WHOM: The State of Oregon, and all of its employees, specifically including but not

limited to the:

Corrections DepartmentDriver and Motor Vehicles (DMV)Education DepartmentEmployment Department

Housing/Community Services DepartmentHuman Services DepartmentLabor and Industries Bureau

TO WHOM: KP Law LLC

PURPOSE: SSI (Supplemental Security Income Title XVI) and DIB (Disability InsuranceBenefits Claim Title II)

Please sign using Blue or Black Ink Only authorizing disclosure:

SIGNATURE:____________________________________________ Date________________


32/56




The preparation of a Social Security Disability case requires the gathering of considerable information.

( ) Please obtain for me a printout from your pharmacy for all medicines.( ) Please send me a list of ALL of your medical, physical therapy, counseling, etc. appointments for

the past 24 months.( ) If you have not done so, please furnish me the names, addresses and telephone numbers of all

witnesses.( ) Please send me a copy of your disabled parking permit, or a copy of an application signed by your

Doctor.

( ) Please send me a copy of 30 days of blood sugar readings.( ) Please send me a copy of your hearing test results.( ) Please send me the name, address and claim number for your old Workers Compensation case.( ) Please send me a copy of all letters you have received from Social Security denying your disability

claim. This includes your current claim, as well as any earlier claims that were denied by the

Social Security Administration.

Whenever you answer questions or fill out a questionnaire for SSA, neither exaggerate or minimize your

condition. SSA will deny your claim easily if you tell them what you can do, or you do not explain that you

have problems doing these things. You want them to see the answers that reflect what you cannot do

and why, or what you do only with difficulty and why. Any SSA questionnaires you fill out should be

returned to ME and NOT to SSA. That way, I can make a copy and if you have said something unwise,

or which might confuse SSA, we can talk about it.

Thank you for your cooperation in this matter.

VERY IMPORTANT:

What is the name, address and telephone number of some one who DOES NOT LIVE WITH YOU, but

will ALWAYS know where your are?

Name:

Address:

City/State/Zip

Telephone:

Relationship:


33/56

AUTHORIZATIONFORRELEASEOFINFORMATION

I authorize ____________________________________________________________________to disclose a copy of the health information described below regarding the following:

Name: _____________________ To: KP Law LLC

Attorneys At Law

SSN:___________________________ 16200 SW Pacific Hwy, Suite H-280DOB:__________________________ Portland, OR 97224(503) 245-6309

(503) 245-6725 FaxThe undersigned hereby authorizes attorney, Melissa N. Kenney, Lisa Porter, or any representative thereof, to obtain information, forthe purpose of obtaining Social Security Benefits.


_____ All Physician/Hospital/Clinic/Emergency/Urgent Care/Dental/Physical Therapy records (including lab, x-ray,diagnostic/consultative summaries), including protected records (if applicable) This authorization does not curtail the ability or inabilityto the condition of general healthcare upon its receipt.

_____ Billing Statements _____ Workers Compensation Records

PROTECTED OR SENSITIVE INFORMATION: I understand that the information used or disclosed pursuant to this authorization may besubject to re-disclosure and no longer be will protected under federal law. I also understand that federal or state law may restrict re-

disclosure of HIV/AIDS information, mental health information, genetic information and drug/alcohol diagnosis.

I authorize the release ofthe following protected or sensitive information:


_____ Drug/Alcohol diagnosis/treatment/or referral _______ Sexually transmitted diseases_____ Psychological and/or psychiatric treatment _______ AIDS/HIV test results, including RELATED_____ Genetic testing information high-risk behaviors


______ Police records _____ Adult & Family Services/Senior Disabled Services Records______ Employment records (Medical and Mental Health Treatment Records)______ Federal, state income records _____ Any and all School records and transcripts including all

counseling/psychological records______ I specifically consent to the FAXing of my records. All FAXed material will contain a confidentiality statement, however,understand confidentiality at the receiving end cannot always be guaranteed.

You do not need to sign this authorization. Refusal to sign the authorization will not adversely affect your ability to receive health careservices or reimbursement for services. The only circumstance when refusal to sign means you will not receive health care service is if thehealth care services are solely for the purpose of providing health information to someone else and the authorization is necessary to makethat disclosure. You may revoke this authorization, please send a written statement to KP Law LLC at the above address and state that you arerevoking this authorization.Unless revoked earlier, this consent will expire 180 days from the date of signing or shall remain in effect for the period reasonably needed tocomplete the request. This authorization is in compliance with HIPAA

PHOTOCOPIES OF THIS AUTHORIZATION ARE VALID AND MAY BE USED IN LIE OF THE ORIGINAL

Clients Name (Please print)___________________________________________

Dated:______________ Clients Signature __________________________________________________

If signed as parent or guardian, this authorization shall apply to the records of the above mentioned individual___________________________________ ___________________________________________________________________Name of Parent or Guardian of Client Parent or Guardians Signature

This is a true copy of the original authorization document. A true copy shall be deemed to be the same as the original thereof.

___________________________________________________________________9/09/2011 Forms/AUTHO Signature of Staff Person


34/56

Social Security Administration Form Approved

Consent for Release of Information OMB No. 0960-0566

TO Social Security Administration

______________________ ___________ ___________________________

Name Date of Birth Social Security Number

I authorize the Social Security Administration to release information or records about me to:

Melissa N. Kenney 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224

Lisa R. Porter 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224

Nanette L Mitchell 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224

Leta Sanders 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224

Rahma Abdulaziz 16200 SW Pacific Hwy, Suite H-280, Portland, OR 97224

___X____ Social Security Number___X____ Identifying information (includes date and place of birth parents names)

___X____ Monthly Social Security benefit amount

___X____ Information about benefits/payments I received ______________ to _________________

___X____ Information aobut my Medicare claim/coverage from _____________to ________________

(specify)____________________________________________________________________

___X____ Medical records

_______ Record(s) from my file (specify)___________________________________________________

_____________________________________________________________________________

I am the individual to whom the information/record applies or that persons parent (if a minor) or legal

guardian. I declare under penalty of perjury that I have examined all of the information on this form and it is

true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or

misleading statement about a material fact in this information or causes someone else to do so, commits a

crime and may be sent to prison, or may face other penalties, or both.

Signature: _____________________________________________________________________________________

(show signature names and addresses of two people if signed by a mark)

Date:_________________________________ Relationship: ______________________________________

Form SSA-3288 (3-2005) EF (3-2005)


35/56

16200SWPacificHwy,Ste.H280*PortlandOR97224*5032456309office/5032962632*www.kplawllc.com*[email protected]

Lisa R.J.Porter,EsqAdmittedinORandWA

MelissaN.Kenney,EsqAdmittedinMD

OfCouncil: DavidB.LowryAdmittedinORandAZ

[DATE]CLIENTADDRESSRE: YourSocialSecurityClaim

Dear ,Wearesendingyoutheenclosedformstocomplete,signandreturntoouroffice.Pleasereturntheseformsassoonaspossible.Pleaseuse(DarkBlackorDarkBlue)inkwhencompletingtheseforms.PleasedoNOTusepencil.EnclosedForms

1. ClaimantsRecentMedicalTreatmentFormHA46312. ClaimantsMedicationsFormHA46323. ClaimantsWorkBackgroundFormHA46334. AuthorizationtoDiscloseInformationtoSSAFormSSA827

Thankyouforyourtimeandattentiontothismatter.Ifyouhaveanyquestions,pleasedonothesitatetocontactouroffice.Yourstruly,

NanetteL.Mitchell,ParalegaltoKPLawLLC,MelissaKenneyandLisaPorter,Attorneys/nmEnclosure(s)


36/56




MEDICAL OPINION RE: ABILITY TO DO WORK RELATED ACTIVITIES (PHYSICAL)

DATE

TREATING PROVIDER NAME AND ADDRESS

Re: CLIENT

Dear Medical Treating Provider:

Please be advised that KP Law LLC represents your patient to help her or him obtain Social

Security disability and/or S.S.I. Benefits.

On behalf of our client, we request your cooperation by completing this questionnaire. This

questionnaire is a significantly important source of evidence that may be used to determine a claimants

inability to work eight hours a day, five days a week. Your information, with a minimum of time effort,

will be most helpful, thank you.

To determine your patients ability to do work related activities on a day-to-day basis in a regular

work setting, please give us your opinion based on your examinations and past medical records of your

client. Please consider how your patients physical capabilities are affected by her or his impairment(s)

based on medical history, chronic findings, symptoms (including differing individual tolerances for pain

and movement limitations), and the expected duration of any limitations that could interfere with work

activities.

Please consult your patient if there is any cost regarding completing this questionnaire, as the

responsibility for the cost is the patients.

Thank you for your time and attention to this important matter. If you have any questions, please

feel free to contact our office at 503-245-6309. You may also fax this document to our fax at 503- 245-6725.

Sincerely yours,

Gloria Cullins, Paralegal


37/56

For each activity shown below, indicate your (1) patients ability to perform the activity; and (2) identify

the medical findings that support your opinion regarding the limitations (such as physical exam findings,

MRIs, lab tests, history, symptoms, etc.).

1. Nature, frequency and length of contact with your patient:______________________________________________________________________________

2. Diagnoses:___________________________________________________________________________________________________________________________________________________

______________________________________________________________________________

3. Prognosis:______________________________________________________________________4. List your patients

symptoms:_____________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

5. Identify clinical findings and objectivesigns:_________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

6. Describe treatment and response to treatment, including side effects of medications, such asdrowsiness, fatigue, dizziness, nausea, memory and concentration deficits,

etc.:___________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________

7. Have your patients impairments lasted or can they be expected to last at least 12 mos?Circle one: Yes No

8. Is it reasonable to expect that your patient would experience substantial difficulty with stamina,pain or fatigue if she or he worked full time, eight hours a day at a sedentary or light level of

exertion? Circle one: Yes No

9. Would your patient likely need to work at a reduced work pace if employed full time, eight hoursa day at a light or sedentary level of exertion? Circle one: Yes No

10.Would your patients health problems be made worse if she or he worked full time, eight hours aday at a light or sedentary level of exertion? Circle one: Yes No


38/56

11.Does your patient have (a) condition(s) that can be expected to result in death?Circle one: Yes No

12. Is your patient a malingerer? Circle one: Yes No13.Do mental health issues contribute to the severity of your patients symptoms and functional

limitations? Circle one: Yes No

What are the psychological conditions affecting your patients physical condition? Circle the ones

that apply:

Depression Anxiety Personality disorder PTSD Other _____________________

14.Are your patients impairments and illness(es) consistent with causing the types of limitations sheor he experiences? Circle one: Yes No

15.How often does your patients experience with symptoms severe enough to interfere with her orhis attention and concentration? Circle one:

Never Seldom Often Frequently Very Frequently

16.To what degree can your patient tolerate work stress? Circle one:Uncertain Incapable of even low stress jobs Capable of low stress jobs

Moderate work stress tolerable Capable of high stress work

17.Please explain the reasons for your conclusion to the questionabove:_________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


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18.Does the patient have one or more impairments that requires her or him to:a. change position or posture more than once every two hours?

Circle one: Yes No

b. Affect her or his walking so much it interferes with the ability to independently initiate,sustain or complete normal activities of daily living?

Circle one: Yes No

c. Have sustained disturbance of gross and dexterous movements OR gait and station in twoextremities? Circle one: Yes No

19. If you answer yes to any of the above, please state what medical findings supportthis:___________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

20.What is your patients maximum ability to stand and walk with normal breaks in an 8 hourworkday: Circle one

Less than 2 hrs About 2 hrs About 3 hrs About 4 hrs

About 6 hrs No limit

21.What is your patients ability to sit with normal breaks in an 8 hour workday:Circle oneLess than 2 hrs About 2 hrs About 3 hrs About 4 hrs

About 6 hrs No limit

22. If your patient must periodically alternate sitting, standing or walking to relieve discomfort:a. How many minutes can your patient sit before changing position?

_______________________________

b. How many minutes your patient stand before changing position? ___________________c. How frequently in minutes must your patient walk around?

________________________________

d. How long in duration must your patient walk each time? __________________________e. Does your patient need to shift at will from sitting or standing/walking?______________f. Will you patient need to lie down at unpredictable intervals during a work shift?

________________________________________________________________________

g. If yes, how often do you think this will happen?________________________________________________________________________

23.What medical findings support the limitations describedabove?________________________________________________________________________

______________________________________________________________________________


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In an average 8 hour work day, rarely = 0% to 5%, occasionally= less than 2.75 hours,

frequently=up to 5 hours.

24.What are your patients limitations in these functions:Frequently Occasionally Rarely Never

Twist

Stoop

Crouch

Climb stairs

Climb ladders

25.Are the following physical functions affected by the impairment? Circle the ones that applyReaching Handling Fingering Feeling Pushing/Pulling

In an average 8 hour work day, rarely = 0% to 5%, occasionally= less than 2.75 hours,frequently=up to 5 hours.

26.How many pounds can your patient lift and carry in a competitive workplace:Frequently Occasionally Rarely Never

Less than 10

10 lbs

20 lbs

50 lbs

27.How are these physical functionsaffected?_____________________________________________________________________________________________________________________________________________________

28.What medical findings supportthis?__________________________________________________________________________

______________________________________________________________________________

29.What are your patients environmental restrictions to:No

restriction

Avoid

concentrated

exposure

Avoid moderate

exposure

Never

Extreme cold/heat

Humidity

NoiseFumes, odors, dust,

gases, poor ventilation

Hazards (machinery,

heights)


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30. State any work-related activities which are affected by her or his impairment such as assistivedevices for ambulation, need to elevate legs, limits on kneeling, or limitations related to a mental

impairment and include the medical findings that support

this:___________________________________________________________________________

______________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________

31.On the average, how often do you anticipate that your patients impairments or treatment wouldcause your patient to be absent from work? Circle one:

Never Less than once a month Once a month Twice a month

Three times a month Four or more times a month

32. If drug/alcohol abuse is present, is/was your patient self-medicating an underlying mental oremotional problem? Circle Yes or No.

33. If drug or alcohol abuse has been present, is/was this the primary/dominant cause of the patientsdisability? Circle Yes or No.

34. If yes, is this a situation where years of past drug or alcohol abuse have resulted in ongoing healthproblems that will now exist even though drug or alcohol abuse may have reduced/abated?

Circle Yes or No.

35. If you are not an M.D., a Psy.D., a Ph.D, or a D.O., do you provide treatment to your patient in aclinic where a supervisory M.D., a Psy.D., a Ph.D, or D.O. is present?

36.Please provide the name of the supervisory M.D., a Psy.D., a Ph.D, or D.O. who supervises yourtreatment of your patient:

_____________________________________________________________________________

Signature________________________________________________________________________

Printed/typed name________________________________________________________________

Address:_______________________________________________________________________________________________________________________________________________________

Telephone:______________________________________________________________________

Date: __________________________________________________________________________


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16200 SW Pacific Hwy, Ste. H-233* Portland OR 97224 *503-245-6309 office / 503-530-8770=Fax No. www.kplaw-llc.com*

Lisa R.J. Porter, Esq.



Of Council: David B. Lowry, Esq.


VIA FAX

[DATE]

Social Security Administration

Local Branch Division St.

RE: [CLAIMANT NAME]

S.S.N.:

Dear SSA:

As you are aware, Melissa Kenney represents the interests of the above claimant in regarding to

helping obtain Social Security Disability Benefits.

Please find enclosed herein the following evidence in regard to this claim:

SSA-1696 Appointment of Representative dated 7/31/12 (1) Two-Tiered Fee Agreement dated 7/31/12 (1) SSA-1695 Direct Payment of Authorized fees (1) KP Law LLC Fee Waiver

Please redetermine this claim in light of the enclosed additional evidence POMS GN 03102.100

and/or GN 03103.010(B)(3).

Thank you for your time and attention to this matter. Should you have any further questions, please

do not hesitate to contact this office.

Yours truly,

Nanette L. Mitchell, Paralegal

KP Law LLC

Melissa Kenney and Lisa Porter, Attorneys

/nm

Enclosure(s)


51/56

16200 SW Pacific Hwy, Ste. H-233* Portland OR 97224 *503-245-6309 /FX No. 503-530-8770 [email protected]

Lisa R.J. Porter, Esq


Melissa N. Kenney, Esq

Admitted in MD

Of Counsel: David B. Lowry, Esq


Date:

Social Security Administration

Local Branch [NAME OF BRANCH]_

RE Claimant: ________________

S.S. N. : _________________

Dear SSA:

Please be advised that KP Law LLC, Melissa N. Kenney and/or Lisa R. Porter attorneys, represents the interests of the above

claimant in regard to helping obtain Social Security Disability Benefits.

Please find enclosed herein the following documents in regard to this claim.

SSA-1696 Appointment of Representative dated __ SSA-3288 Authorization to Release Information dated ______ SSA-1695 Identifying Information for Possible Direct Payment of Authorized Fees SSA-827 Authorization to Disclose Information Two-Tiered Fee Agreement dated ____

Please send us a copy of the Claimants earnings record, the Primary Insurance Amount and the Date Last Insured.

PIA: $______________________ PFD:____________________DLI:______________________

Onset Date ___________________________

Please re-open any prior claims and award benefits.

We also suggest that you obtain records from the following medical providers:

Thank you for your time and attention to this matter. If you have any questions, please feel free to contact this office.

Sincerely,

Nanette L MitchellNanette L Mitchell, Paralegal to

Melissa N. Kenney and Lisa R. Porter, Attorneys

/nm

Enclosure(s)


52/56

Page 1 of2 5/23/11

STANDARD FEE AGREEMENT - FEDERAL COURT

SOCIAL SECURITY DISABILITY/SSI

ATTORNEYS FEE:I employ Lisa R. Porter, Attorneys at Law, to represent me before the

Federal District Court and Circuit Court in my Social Security Disability case, SupplementalSecurity Income (SSI) case, or both. If I win in Federal Court, I agree that my attorneys fee

will be authorized by the Court pursuant to the Equal Access to Justice Act (EAJA) and

that this amount will be based upon the hours spent by the attorney on my case. This

amount is paid by the Federal Government and not out of any SSD/SSI benefits that I may be

awarded. I assign to my attorney, any right to EAJA fees that I may be awarded in my

Federal Court case. I authorize my attorney to deposit EAJA fees in her own account for

her own benefit. I understand that fees authorized by the Court for a successful appeal does not

affect my agreement with Lisa R. Porter, for representation before the Social SecurityAdministration. I understand that the attorneys fee in Federal Court depends on winning my

case. If I do not win, then the attorneys get no fee.

CONTINGENT FEDERAL COURT ATTORNEYS FEE

I and my attorneys agree that if it is necessary to appeal this case to federal court, the attorneys

fee for representation before the court is separate from and in addition to any fee for

representation before the agency. The federal court attorneys fee shall be the GREATER of thefollowing:

1) 25 (twenty-five)percent of the past-due benefits resulting from my claim or claims(which I understand may exceed $750.00 per hour), OR

2) The amount of any award ordered pursuant to the Equal Access to Justice Act(EAJA). EAJA fees are paid by an agency of the U.S. government-not out of the

claimants past-due benefits. To the fullest extent permissible under law, I assign tomy attorneys the right to receive any EAJA award(s) or check(s) in payment of

award(s) directly in the attorneys names. My attorneys shall have the beneficial

interest in the EAJA fee award. See 31 C.F.R. 285(e)(5)(2010. If the government

issues checkes in my (the claimants) name for fees costs or expenses under an lawwhich shifts to th

entire clark cnty presentation materials packet for practitioners

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