VA Pre-Qualification Referral Form

VA Pre-Qualification Referral Form

Home Instead (LaGrange/Elmhurst, IL)
Home Instead partners with the Veterans Affairs Administration and the Veterans Care Coordination to help you maximize the home care benefits you have earned!
Personal Information
Client's Name*

(First Name)(Middle Name)(Last Name)
Client's Date of Birth:*

MonthDayYear
Date
Client's Phone Number:*
Phone Number
Address

(Street Address)

(Street Address Line 2)

(City)(State)

(Zip Code)
Client's VA Affiliation - Choose One:*

VeteranSurviving Spouse
OPTIONAL: Has the Client recently been seen by a VA-affiliated primary care physician or VA hospital?

YesNo
If so, please include the name of the physician and/or VA Hospital below?
Was the Veteran honorably discharged?*

YesNo
Did the Veteran serve at least 90 consecutive days of active duty, with at least one day during any of the following wartime periods?

World War II [12/7/1941-12/31/1946]Vietnam [8/5/1964-5/7/1975]Korean War [6/27/1950-1/31/1955]Gulf War [8/2/1990-TBD]Republic of Vietnam [11/1/1955-8/4/1964]Other
If surviving spouse, were you married to the veteran at the time of death?*

n/aYesNo
Is there a need for assistance with ADLs or IADLs (including Bathing, Dressing, Transportation, Incontinence, Housekeeping, Laundry, Cooking, Shopping, Medication Reminders, Ambulation, or Custodial Care)?*

YesNo
What email address would you like VA referral information sent to?*
(example@example.com)
Miscellaneous Information:
Should be Empty: