Abundant C&P Intake

Intake Form Date

Date

Full Name (First, Middle, Last)

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:

Format: (000) 000-0000.

Birthday

SSN

This is a secure site and document. Please type your entire SSN.

Please upload a picture of your Driver's License or Picture ID

Take Photo

Are you Signed Up for E-Benefits? If not, please sign up by going to ebenefits.va.gov as you will need the information there throughout this process.

Branch (Click All that Apply)

Active Duty Dates (as listed on DD-214)

Please list the dates from your DD-214

Active Duty Entrance Date (as listed on DD-214)

Date first entered service

Active Duty Exit Date (as listed on DD-214)

Date released from service entirely.

Were you in the Reserves or National Guard?

Reserves/National Guard Years

What were the years you were in the Reserves or National Guard?

Were you in Combat during Deployment? If Yes, please list Dates and Location in "Other" field

Other

Deployment Locations and Years:

Please list deployment locations and dates. If multiple deployments, please list each one and the dates of each.

Please Upload DD-214, if available

Please upload your DD-214s here

MOS/Duties

Service Connection Total Combined Disability Percentage (per e-benefits or most recent ratings per VA decision letter)

Please Upload the most recent Copy of your Individual Disability Ratings List or ratings code sheet. THIS IS MANDATORY!!! If you do not have a copy of the Table of Rated Disabilities Ratings list, please go to e-benefits, go to the tab on the left that says disabilities, and the information pulls up. Please save upload this document here. DO NOT SEND SCREENSHOTS of the ratings sheet or of your computer screen.

Ratings Disability list or Ratings Code Sheet

Individual Service Connection Conditions and Ratings per VA or e-benefits Table of Rated Disabilities/Rating Sheet. Please type out each condition/claim from the above stated file that you downloaded from e-benefits (the rated disabilities ratings sheet). Please don't guess the condition or input what you think the condition is listed as. Please enter this information from your ratings list or ratings code sheet.

Rows	Service Connected Condition per Rating Decision Sheet	Claimed as: (if different from the claim that was granted. For example "back condition" or "sinus"). This should be the condition that was listed on your claim request	Percentage as listed on code sheet. Please list 0% if that is how it is listed on the rating list or code shee	Date Granted (this is the date the VA granted the claim)	Effective Date (this is the date they listed as effective on the code sheet, i.e. the date your payments were back paid to)
Condition #1
Condition #2
Condition #3
Condition #4
Condition #5
Condition #6
Condition #7
Condition #8
Condition #9
Condition #10

Denied Claims List:

Rows	Denied Condition	Condition Claimed as (if listed)	Reason Denied (per decision letter)
Denied Condition #1
Denied Condition #2
Denied Condition #3
Denied Condition #4
Denied Condition #5
Denied Condition #6
Denied Condition #7
Denied Condition #8
Denied Condition #9
Denied Condition #10

Please list any currently pending or claims in process but not yet rated. Please also list how long the claim has been pending.

List any currently open claims that are pending and have not been given a rating yet. Also list the date that it was filed.

Do you have an intent to file already open for the claim you're wanting to file?

List the Date the intent to file was started/filed

VSO, claims agents, law firms, people who filed your prior claims, or list if you filed them on your own:

For Example: VFW, American Legion, DAV, Self, E-Benefits, NABV, etc.

Who Referred you to Abundant C&P:

Please list: Name, FB Group, Website, Google Search, etc.

Current Complaints/Concerns/Claims they are seeking (in patient's words)

Do You have Copies of Service Treatment Records from active duty?

If not, have you requested them from Archives.gov, The Regional office, or Tricareonline, and are waiting for them to be found and sent to you?

Do you have access to your entire c-file (the VA file with all of your claims information including your service treatment records, personnel records, dd-214, entrance and exit exams, disability ratings, decision letters, etc)? If not, please request this by completing VA form 21-4138 or fill out the request for service records VA form 20-10206. These forms can be downloaded at www.va.gov

Active Duty Service Treatment Records (if these are located in your c-file download records, please upload the entire c-file here, otherwise, upload all available pages of your active duty service records here. Please do not send excerpts of the service records as all available records will need to be reviewed).

Please upload a copy of your service records from active duty

Do you have copies of current VA and Civilian Medical Records?

Are you able to/Do you have access to MyHealthE-Vet?

Please download the MyHealthE-vet blue-button health records and upload the pdf file here. (Downloading the entire file is best, but at least the last 10 years is the minimum. Please change the date on the download request to 01/01/1990 so that ALL of the VA records will be downloaded. If you don't put this date in, it will ONLY send the last 6 months of records. You also need to change the option to download entire record.) This will help us build your case for your claims.

Please go to the blue button download in myhealthevet and use the option to download the ENTIRE file and specify dates of 01/01/1990 to present and upload the downloaded file here.

Who is Your Primary Care provider at the VA? If you do not go to the VA for care, please type N/A. If you do not know the provider's name, please list the team or the last doctor seen at the VA.

Please type the name of your Primary Care Provider/Manager or the team you are on at the VA

Do you see a Specialists at the VA? If so, list name and specialty:

Do you have a Civilian Primary Care Physician? If so, list Name and Specialty

Do you have access to electronic medical records from your civilian PCP?

Civilian PCP medical Records

Electronic medical records from civilian primary care or urgent care

Do you see Civilian Specialists (Ortho, GI, Cardiology, Nephro, etc.)? If so, list name and specialty

Do you have access to electronic medical records from your civilian Specialists?

Please Upload VA and/or Civilian PCP Medication List. (If you have uploaded your entire MyHealtheVet VA Blue-button records, the medication list will already be included and you do not have to include an extra file. If you have uploaded your civilian medical PCP or specialist records, your medications should already be included and you do not have to include this extra file)

Upload any medication lists or documentation not already uploaded in your electronic medical record files

Medication List *

Prior/Expired/Discontinued Medication List:

Problem List/Clinical Diagnoses as listed in your medical records (civilian or VA)

Please upload Civilian PCP Problem List or VA medical records problem list. If you have uploaded your entire bluebutton myHealtheVet records, you do not need to upload a separate problem list as it should already be listed in the file.