Representative Payee Referral Form

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Representative Payee
Referral Form
Date: ____________________
Client Name: __________________________________________
SSN: ____________________________
Contact Phone Number: _____________________________
__________________________________________________________________________________________________
Referred by: __________________________________________
Phone: __________________________
Does the beneficiary have a current payee?
YES
NO
If yes, list current payee: ______________________________________________________________________________
List reason for changing: _____________________________________________________________________________
If no, please have the beneficiary’s physician fill and sign SSA-Form 787 (Physician Form on our website)
Type of Benefits Received:
SSA
SSI
VA
Railroad Retirement
Client Situation Notes:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Level of Urgency? (1 being low, 10 being emergent) __________
Urgency about level 5, please print and complete our Representative Payee Intake Packet.
Client Signature
Date
Authorized Representative
Date
Reviewed by:______________________________________________
Date: ___________________
Return this form
Mail to: 1100 Rutherford Road Greenville SC 29609
Fax to: 864-467-3571

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