Patriot DBQ Services – Veteran Intake & Consent Form

Patriot DBQ Services – Veteran Intake & Consent Form

(HIPAA Compliant)
Name

First NameLast Name
Date of Birth
Date

MonthDayYear
Date

Area Code Phone Number Email Street Address Address Line 2 City State Zip Last 4 of SSN This is a fill in the blanks field. Please add appropriate blank fields and text.

What conditions are you seeking support for?

Are you currently working with a physician or attorney?

YesNo

If yes, please list name and contact info

Years of Service

Deployment Locations

Exposure History Burn Pits, Pesticides, Diesel Fumes, etc

Additional Comments

Upload your Blue Button Report (File Upload - PDF preferred)

Cancelof

I authorize Patriot DBQ Services to review my VA records strictly for documentation preparation.

Authorized

I consent to Patriot DBQ Services handling my PHI in accordance with HIPAA and HITECH compliance standards

Authorized

Date Signed

MonthDayYear
Date

Schedule a Claim Strategy Session

YesNo

Request Provider Referral Coordination

YesNo

Request Legal Referral (no fee)

YesNo

Signature

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