O'Brien & Feiler Eligibility Screening Tool Is the patient unemployed or working fewer than 20 hours per week as a result of a severe health issue? Yes No This Medical Provider works with a firm that helps patients secure SSI/Disability benefits which can unlock health coverage. You can discuss your situation with them for free and determine whether filing for SSI/Disability would be an option. May I have your permission for them to contact you? Yes No Patient Name First Name Last Name Patient Date of Birth Patient Phone Patient Email example@example.com Hospital Name / Staff Initials If the answer to the both questions is “yes”, then hit "Submit" and OBF will contact the patient. Submit Should be Empty:
