B. J. Walker, Commissioner

Gwendolyn B. Skinner, Division Director

Georgia Department of Human Resources • Division of Mental Health, Developmental Disabilities and Addictive Diseases

Two Peachtree Street, NW • Suite 23-215 • Atlanta, Georgia 30303 • 404-657-2134

Re: John Smith

DOB: 01/01/1950

SSN: 555-55-5555

October 19, 2015

Social Security Administration

401 W. Peachtree St. Suite 2860

Atlanta, GA 30308

To Whom It May Concern:

This letter serves as a request for an On-the-Record favorable decision of the SSI application for Mr. John Smith.

Mr. Smith has been diagnosed with Chronic Schizophrenia, undifferentiated type and has been experiencing homelessness, living on the street for the last 10 years. He has been living on the street and has been hospitalized and incarcerated countless times due to the severity of his symptoms and inability to function at a basic level. Mr. Smith’s illness is so severe that he is unable to care for his daily needs. He requires an intensive support system to remain stable and is unable to function outside a highly supportive living arrangement.

Mr. Smith meets listing 12.03 Schizophrenic, paranoid and other psychotic disorders. As documented in the attached medical records from Georgia Regional Hospital-Atlanta and Grady Memorial Hospital he experiences hallucinations, disorganized thoughts and a blunt affect. Mr. Smith is severely functionally impaired as documented in the attached Mental Impairment Questionnaire completed by his psychiatrist at Grady Hospital, Dr. Judy Smith; and collateral letters from volunteers at the Open Door Community. Mr. Smith has marked restrictions in his activities of daily living as evidenced by his inability to properly use a restroom, cook or clean for himself and care for his personal hygiene needs. He has marked difficulties in maintaining social functioning including aggression and violence which have led to incarceration and hospitalization. Mr. Smith has marked difficulties in maintaining concentration, persistence, and pace. He becomes very distracted and cannot stay in one place for very long without becoming very anxious. Mr. Smith has experienced repeated episodes of decompensation for the past 10 years. He has been living on the street except for the countless times he has been arrested and incarcerated or hospitalized on a 1013 for aggression, violence, hallucinations and disorganized thoughts.

Mr. Smith meets the Social Security Administration’s criteria for disability and we request that his application be reviewed on the record so that Mr. Smith can begin receiving benefits and access the intensive supportive housing and treatment services that he needs to end his homelessness.

If you have any questions, please do not hesitate to contact me at (404) 657-5555. Thank you for your assistance and consideration.

Sincerely,

Jane Doe, LMSW

SOAR Benefits Specialist

Enclosures:

Mental Impairment Questionnaire, Dr. Judy Smith, Grady Memorial Hospital (3 pages)

Collateral Letter on Functioning, Jane Adams, The Open Door Community (2 pages)

Collateral Letter on Functioning, Jon Adams, The Open Door Community (2 pages)

SSA-1696, Appointment of Representative, Jane Doe, DHR Office of Mental Health (1 page)

SSA-827, Authorization to Release Information, John Smith (1 page)

Georgia Regional Hospital-Atlanta, Medical Records (18 pages)

Grady Memorial Hospital, Medical Records (8 pages)

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