Full Name (First, Middle, Last)
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Intake Form Date
-
Month
-
Day
Year
Date
Phone Number:
*
Birthday
*
SSN
*
Please upload a picture of your Driver's License or Picture ID
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Branch (Click All that Apply)
*
Army
Navy
Air Force
Marines
Coast Guard
Other
Active Duty Dates (as listed on DD-214)
*
Were you in the Reserves or National Guard?
*
NO
Yes, National Guard
Yes, Reserves
Yes, BOTH
Reserves/National Guard Years
Deployment Locations and Years:
Were you in Combat during Deployment? If Yes, please list Dates and Location in "Other" field
*
NO
YES
Other
Please Upload DD-214, if available
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MOS/Duties
Service Connection Total Combined Disability Percentage (per e-benefits or most recent ratings per VA decision letter)
Not Service Connected
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
100% P & T (Permanent and Total)
Please Upload Copy of your Individual Disability Ratings List. 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 and either print or send this document. DO NOT SEND SCREENSHOTS.
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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)
*
Service Connected Condition per Rating Decision Sheet
Claimed as (if different)
Percentage
Date Granted
Condition #1
Condition #2
Condition #3
Condition #4
Condition #5
Condition #6
Condition #7
Condition #8
Condition #9
Condition #10
Denied Claims List:
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
VSO (or person who filed/uploaded your former claims):
*
For Example: VFW, American Legion, DAV, Self, E-Benefits, NABV, etc.
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.
*
Please Select
YES, and I use it
YES, but username/password forgotten
NO, I am not Signed-Up
Who Referred you to Abundant C&P:
*
Please list: Name, FB Group, Website, Google Search, etc.
Do You have Copies of Service Treatment Records from active duty?
*
Please Select
YES
NO
Requested, Have not received yet
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?
*
Please Select
YES, Requested
YES, Requested but records can not be found
NO, Have not requested
N/A, Already Have Copies
Active Duty Service Treatment Records
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Please upload a copy of your service records from active duty
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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
*
Yes, I have my entire c-file
I have requested my c-file and am waiting for it to be sent
No, I do not have my c-file
Do you have copies of current VA and Civilian Medical Records?
*
Please Select
YES, BOTH
YES, VA ONLY
YES, CIVILIAN ONLY
NO
Are you able to/Do you have access to MyHealthE-Vet?
*
YES
NO
Please download the MyHealthE-vet blue-button health records (downloading the entire file is best, but at least the last 10 years is the minimum) and upload the pdf file here. This will help us build your case for your claims.
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Who is your Primary Care Manager at the VA?
Please type the name of your Primary Care Provider/Manager or the team you are on at the VA
Do you have a Civilian Primary Care Physician? If so, list Name and Specialty
Do you see a Specialists at the VA? If so, list name and specialty:
Do you see Civilian Specialists (Ortho, GI, Cardiology, Nephro, etc.)? If so, list name and specialty
Current Medication List:
*
Prior/Expired/Discontinued Medication List:
Please Upload VA and/or Civilian PCP Medication List
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Problem List/Clinical Diagnoses as listed in medical records or myhealthevet:
*
Please Upload VA and/or Civilian PCP Problem List
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Current Complaints/Concerns/Claims they are seeking (in patient's words)
Preview PDF
Submit
Should be Empty: