AT ADVOCACY PROJECT
SURVEY/DOCUMENT RETURN
NAME: _______________________________________
AGENCY, FIRM (if any): ________________________________________
_____________________________________________________________
CITY, STATE, ZIP: ______________________________________________
TELEPHONE, FAX: ________________________________________
Will you accept referrals of AT cases? yes ____ no ___
Check types of cases you will accept:
Medicaid: ____
Medicare: ____
Private Insurance: ____
SSI PASS: ____
VESID, Commission for Blind: ____
Special Education: ____
Physically Handicapped Children's Program: ____
Veteran's Benefits: _____
ADA, section 504: ____
Other, please
list:___________________________________________________
_________________________________________________________________
_________________________________________________________________
Counties you serve:
____________________________________________________
____________________________________________________________________
Do you charge a fee? _______
Please enclose documents (e.g., hearing decisions, court papers) that we can include in our database.
Are there any specific issues you would like to see covered in future newsletters? Please list:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
If the IMPACT newsletter did not come to you, or your agency/firm, would you like to be added to our mailing list, please print your name, agency, and address below.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
______________________________________________________________
Please complete and return to:
MARGE GUSTAS,
Neighborhoold Legal Services, Inc.
295 Main Street, Room 495
Buffalo, New York 14203