• VA Disability Intake Form

    VA Disability Intake Form

    We are here to walk you through the process of obtaining VA disability benefits. Please complete this intake form and we will contact you via email within 1-2 business days to discuss the next steps to appoint OSDRI as your representative.
  • Date
     - -
    4 digit year, 2 digit month, 2 digit day

  • Your Contact Information

  • Format: (000) 000-0000.

  • Your Information (continued)

  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Gender*

  •  

    Count biological, step, or adopted children who live with you full time and are:
    • Under age 18, or
    • 18–23 and in school full-time, or
    • Any age if they became disabled (permanently incapable of self-support) before 18.

  • How Did You Hear About Us?

  • Special Circumstances

    Sometimes the VA will move a case faster in emergencies. Tell us if any of these apply to you here.
  • Right now, do any of the following describe your current situation? (Check all that apply.)*
  • Can you provide copies of the following? (check all that apply)*

  • *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.

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  • Your Time in Service

    Tell us about your military service
  • State (if National Guard)*
  • Are you still in the National Guard or Reserves?*
  • Date of Entry*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date of Discharge*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Are you still on Active Duty?*
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  • Do you have another period of service?*

  • Second Period of Service

  • (Second) State (if National Guard)*
  • (Second NG) Are you still in the National Guard or Reserves?*
  • (Second) Date of Entry*
     / /
    2 digit month, 2 digit day, 4 digit year
  • (Second) Date of Discharge*
     / /
    2 digit month, 2 digit day, 4 digit year
  • (Second) Are you still on Active Duty?*
  • Do you have more than two periods of service?*

  • Third Period of Service

  • (Third) State (if National Guard)*
  • (Third NG) Are you still in the National Guard or Reserves?*
  • (Third) Date of Entry*
     / /
    2 digit month, 2 digit day, 4 digit year
  • (Third) Date of Discharge*
     / /
    2 digit month, 2 digit day, 4 digit year
  • (Third) Are you still on Active Duty?*
  • Do you have more than three periods of service?*

  • While there are limited exceptions, you must have at least one period of honorable service or service under honorable conditions in order to be eligible to receive VA disability compensation. 

    If you do not have a period of service under honorable conditions and you need assistance upgrading your discharge status, please email Dan Evangelista or call him directly at (401) 474-4764.

  • Combat Service

  • Did you serve in combat?*
  • After any blast, did you experience any of the following symptoms? (Check all that apply.)
  • While you were in service, did a doctor ever tell you that you had a concussion or traumatic brain injury (TBI)?*
  • Did you experience any sleep disruption, hypervigilance, or headaches during service?*

  • Your MOS Duties

  • If you were in the National Guard or Reserves, your active duty time is when you were in: (1) basic training, (2) advanced individual training (AIT) or specialized training, and/or (3) all deployments or overseas service. If you are not sure how much of your service was considered active duty, please contact us for clarification.

  • Which of the following best describe the type of work you did in service? (Select ALL that apply)*

  • MOS: Physical

    These questions help us understand wear and tear on your body from service.
  • (Physical) What types of physical activities did you perform regularly while you were in service?*

  • MOS: Administrative

  • (Administrative) Do you have any of the following symptoms?*

  • MOS: Fuels

  • During your time in the military, did your job require you to drive, ride in, or work on any vehicles? (Select ALL)*

  • Noise Exposure

  • Which of these weapons were you around regularly in the military? (Check all that apply)*
  • On average, how many hours per week were you around gunfire, artillery, aircraft, engines, or generators?*

  • Presumptive Exposures

    Agent Orange, Burn Pits, Camp Lejeune
  • Which environmental or deployment toxins were you exposed to during service? Select ALL that apply.*

  • Agent Orange

  • Agent Orange - Did you serve in any of the following locations?*

  • Burn Pits

  • Image field 230
  • Burn Pits - Did you serve in any of the following locations?*

  • Camp Lejeune

  • Image field 100
  • (CL) Did you serve in any of the following locations for at least 30 days?*

  • Chemical Exposures

  • Do you believe you may have been exposed to any of the following hazardous materials during service?*

  • For more information on potential exposures during service, click here. 

  • Asbestos

  • For more information on how you may have been exposed to asbestos in service, visit mesothelioma.net

  • Depleted Uranium

  • Jet Fuel

  • Mustard Gas

  • Firefighting Foam (PFOS/PFAS)

  • Radiation

  • MOS: Other Exposure

  • Your Current Benefits

  • Are you currently receiving or have you received any of the following? Select all that apply.*

  • You have one year to appeal a Rating Decision. If your appeal deadline is coming up, it is important that we know there is an upcoming appeal deadline, so we can expedite your initial workup if necessary.

  • How Are Your Current Symptoms Related to Service?

  • To get VA disability benefits, at least one of your medical conditions must be connected to your military service.This means:• It started while you were in the military, OR• It was caused by something that happened in service, OR• Service made a pre-existing condition worse.*

  • Why Do We Ask This? Sleep apnea is a common condition we can often link to military service, even if you didn't have symptoms in service. If you have other service-connected conditions, we can often link sleep apnea to one or more of those conditions to increase your overall combined rating. 
     

  • Your Current Symptoms

  • Please list ALL doctors or medical facilities you have been to since you were discharged:*

  • Medications

  • Please list ALL medications you are currently taking:

  • Employment

  • Last Date Worked Full Time*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Do your medical conditions keep you from working full-time (about 40 hours per week) in any job?*
  • Do you have access to reliable transportation?*

  • Any Additional Information

  • Please DO NOT file claims on your own or contact the VA directly about your case. This includes calling the VA, submitting any claims online, or responding to letters on your own. Filing claims on your own may delay or damage your case. If you file a claim outside of our process, it can interfere with the strategy we’re building and create confusion that often causes significant delays and weakens your case. Our legal team knows what the VA is looking for, and what they often miss. Our job is to fight for you, and we can only do that if we can manage the entire process. 

    If you file claims on your own, we WILL withdraw from representation on your behalf. 

    Have a question about something the VA sends you? Just send it to us. We’ll walk you through exactly what it means and what we need to do.

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  • PLEASE READ!!

    Here are the few things we need you to agree to before we can enter into representation in your case
  • Do you have questions about OSDRI's Fee Agreement and how it all works?*

  • UNDERSTANDING OUR FEE AGREEMENT

    Operation Stand Down RI (OSDRI) provides free help with the initial piece of your VA disability claim. We only get paid if we pursue an appeal or re-open a claim (Supplemental Claim, Higher Level Review, oe Notice of Disagreement) and are successful. We only get paid if we win on appeal - we represent you at no cost on your initial claim (526EZ). 

    When we get paid:
    We only collect a fee after the VA issues a decision on your claim and we file one of the following within the required deadline: a Higher-Level Review, a Supplemental Claim, or a Notice of Disagreement/appeal. If you don't win, or if none of these filings happen, we don't get paid.

    How much:
    If you win, our fee is 20% of the past-due (back pay) benefits the VA awards you. This is the maximum percentage allowed by federal law. We never take a percentage of your ongoing monthly VA payments going forward — only from the lump-sum back pay.

    How we are paid:
    The VA pays us directly out of your back pay. You don't write us a check. If for some reason the VA doesn't pay us directly, you're still responsible for paying the 20% fee to OSDRI.

    No guarantees:
    We will work hard on your case, but we can't promise a specific outcome. No one can guarantee you will win your claim.

    If you appeal to Federal Court:
    If your case goes to the U.S. Court of Appeals for Veterans Claims, we may seek additional fees from the government (not from you) under the Equal Access to Justice Act, and you authorize us to process that payment on your behalf.

    Your right to end representation:
    You may fire OSDRI at any time. If you do, or if we withdraw from representation, we may still retain the right to 20% of any future back pay that results from work we already did on your appeal. 

    Replacing prior representation:
    Signing this agreement cancels any previous Power of Attorney you had on file with the VA or the Court of Appeals for Veterans Claims for a different attorney, agent, or service organization.

    Your responsibilities:
    Be honest with us, respond when we reach out, keep us updated on major developments in your claim, and let us know right away if your address or phone number changes.

  • Still have questions? Email us here. 

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