Update My Information
If any of your information has changed, please complete the following:
Name
*
First Name
Middle Initial
Last Name
Email
example@example.com
What type of information do you need to update us about?
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New Contact Information
Provide an Emergency Contact Person
New Medical Treatment
New Medication
Employment Status
Extreme Circumstances
Other Information
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Contact Information
New Home Address
Street Address
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City
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Please enter a valid phone number.
Format: (000) 000-0000.
New Email Address
example@example.com
Preferred Method of Contact
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Please Select ONE
Phone
Text
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Emergency Contact Information
Provide an emergency contact person who can get in contact with you if we are unable to contact you throughout the process.
Emergency Contact Name
First Name
Last Name
Relationship to You
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Email Address
example@example.com
OSDRI may contact this individual if they are unable to contact me about my VA disability case:
*
I Agree
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Medical Treatment
CLICK HERE TO BE REDIRECTED TO THE TREATMENT HISTORY FORM
List ALL medical providers you have seen since you were discharged from service:
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Medications
Please list all of the medications you currently take:
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Employment
What is your employment status?
Please Select
Full Time
Part Time
Retired
Self Employed
Student
Unemployed
Medical Leave
Last Date Worked
/
Month
/
Day
Year
Date
What is your occupation?
Are you unable to work full time because of your disabilities?
Yes
No
Do you have access to reliable transportation?
Yes
No
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Extreme Circumstances
In order to request priority processing of your case, we need evidence to support this request. We will put together this request to submit with the evidence you provide.
Do any of the following apply to you?:
Homeless
Immediate Risk of Homelessness
Severe Financial Hardship
Terminal Illness
Age 85+
None of the Above
Can you provide copies of any of the following?
Eviction or Foreclosure Notice
Past-Due Utility Bills
Collection Notices from Creditors
Statement of Homelessness
Treatment Record Showing Terminal Illness
Statement of Financial Hardship
None
Other
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Other Information
What additional information would you like to provide?
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