2024 Intake Form

VA Disability Intake Form

Thanks for visiting us! We’re here to help with your VA disability case. Please complete this intake form and we will contact you via email within 3-5 business days to discuss the next steps to appoint OSDRI as your representative.
PLEASE NOTE!

As a non-profit organization with limited resources, we must carefully allocate our time and energy to ensure that we provide the best possible support to our clients. Therefore, we are not accepting the following cases:
- if you are currently rated at 90% (you receive $2,241.91 or more from the VA each month) and you are gainfully employed, or
- if you are currently rated at 100% (you receive $3,737.85 or more from the VA each month), or
- if you do not have a period of service under honorable conditions. For more information on upgrading your discharge status, please contact Dan Evangelista at danielevangelista9@gmail.com or at (401) 474-4764.

Contact Information

Provide some basic information so we can contact you.
Date

MonthDayYear
Date
Your Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Email Address*
example@example.com
Date of Birth*

MonthDayYear
Date
Age
Gender*

MaleFemale
Social Security Number (SSN)*
VA Claim Number
*If you're not sure, this is most likely the same as your SSN, but we can fill this in later.
How did you hear about us?*
If "Other" please explain below
Who referred you?*
If "Other" - How did you hear about us?
What is your preferred method of communication? Select ONE*

Employment
Employment Status*
Occupation*
If you are not currently working, put your most recent job
Last Date Worked Full Time

MonthDayYear
Date
Are you unable to work full time because of your medical conditions?

YesNo
Monthly Income*
*This information is required for grants we receive to fund various programs for veterans. We will not release this information to anyone without your explicit permission.
Do you have access to reliable transportation?*

YesNo

Medical Conditions
What are your current medical conditions? List ALL current symptoms that you have talked to a doctor about that interfere with your day-to-day life.*
From your answer above, which of these medical conditions do you believe may be related to your military service?*
In order for us to help with your disability case, you MUST have at least ONE medical condition or set of symptoms that you believe was incurred while in active-duty military service that continues to affect you today.*

I certify that I have at least ONE condition or symptoms that affects me today that I believe is related to my military service.I DO NOT have at least one condition or symptoms that affects me today that I believe is related to my military service.
Have you treated anywhere outside of the VA Medical Center since you were discharged?*

YesNo
If you have treated anywhere outside of the VA since you were discharged from service, please let us know.

There will be a separate link to complete your treatment history once you submit this intake form. This form will also be emailed to you to complete shortly after you submit your completed intake form.
If you have not told a doctor about your symptoms, our options to pursue your claims may be significantly limited. Due to the lack of medical evidence directly linking your conditions to your military service, especially considering the time since you were discharged, establishing a link to service may be extremely challenging. Ongoing medical treatment are essential to support your claims effectively.*

I have not talked to a doctor about my symptoms. I understand without a record of treatment it may be difficult to pursue my claims.
Do you have a current diagnosis of sleep apnea?*

Client Memorandum of Understanding

The below Memorandum of Understanding outlines the most important principles and expectations we need you to agree to in order to provide competent and valuable representation. By completing this intake and clicking Submit, you agree to abide by each and every term of this agreement to help facilitate OSDRI's representation on your behalf.
I consent to receive communications from OSDRI via email and/or text message. I understand I can opt out of these communications by notifying OSDRI in writing.*

I understand and agree to this term
I understand that communicating with the VA while represented by OSDRI frustrates the claims process and can lead to unnecessary delays in my case. I agree to consult my representative if I wish to file additional claims while represented and agree not to submit claims independently while represented by OSDRI.*

I understand and agree to this term
I agree to actively participate in the process by providing information requested by my representative. I understand it is important to remain in contact with my representative in order for OSDRI to provide adequate representation on my behalf.*

I understand and agree to this term
I agree to attend Comp & Pen Exams scheduled by the VA or reschedule the exam if necessary. I understand that failing to attend a scheduled Comp & Pen Exam may result in the outright denial of my claim.*

I understand and agree to this term
Should be Empty:

VA Disability Intake Form

PLEASE NOTE!

Contact Information

Dependents

Special Circumstances

Service Information

Potential Exposures

Current Benefits

Employment

Medical Conditions

Goal for Your Case

Client Memorandum of Understanding