• HIPAA Compliant Intake Form

    Please fill out your details and upload relevant documents to complete your intake.

  • Demographic

    Personal and contact details
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Gender

  • Attorney/VSO Representation

    Tell us whether you have representation and share their contact details if applicable.
  • Do you have an Attorney or VSO representing you?*
  • Format: (000) 000-0000.
  • Records Available*

  • MOS

    Military occupational details
  • Branch of Service

  • Dates of Service

    Service date information
  • Start Date of Service*
     - -
  • End Date of Service*
     - -

  • Deployment

    Deployment details

  • TERA Questions

    Toxic exposure and risk activity questions
  • Are you claiming any conditions related to Toxic Exposure Risk Activity (TERA)?*
  • Any Non-Deployment Toxic Exposure Risk Activity (TERA) Related to MOS/AFSC/NEC?*
  • Did you serve in any of the Gulf War hazard locations? Iraq; Kuwait; Saudi Arabia; the neutral zone between Iraq and Saudi Arabia; Bahrain; Qatar; the United Arab Emirates; Oman; Yemen; Lebanon; Somalia; Afghanistan; Israel; Egypt; Turkey; Syria; Jordan; Djibouti; Uzbekistan; the Gulf of Aden; the Gulf of Oman; the Persian Gulf; the Arabian Sea; and the Red Sea.
  • Did you serve in any of the following herbicide locations? Republic of Vietnam to include the 12 nautical mile territorial waters; Thailand at any United States or Royal Thai base; Laos; Cambodia at Mimot or Krek; Kampong Cham Province; Guam or American Samoa; or in the territorial waters thereof; Johnston Atoll or a ship that called at Johnston Atoll; Korean demilitarized zone; aboard (to include repeated operations and maintenance with) a C-123 aircraft known to have been used to spray an herbicide agent (during service in the Air Force and Air Force Reserves).
  • Have you been exposed to any of the following?

  • Claimed Conditions

    Medical conditions and claim description
  • Type of Claim*

  • Housing status

  • Currently experiencing Homelessness *

  • HIPAA

    Secure upload and acknowledgment
  • Authorization for Release of Medical Records and Protected Health Information I hereby authorize any physician, hospital, clinic, therapist, counselor, pharmacy, laboratory, imaging facility, or other healthcare provider that has examined, treated, or provided services to me to release, disclose, and furnish to Dr. Kenneth Hammonds and/or Professional Medical Services any and all medical records, reports, billing records, diagnostic studies, test results, correspondence, and other protected health information in their possession that relates in any way to my claimed medical conditions, treatment history, and claim for benefits. I understand that this authorization is made for the purpose of medical-legal review, evaluation, consultation, and preparation of reports or opinions related to my claim. I understand that the information disclosed may include information regarding diagnosis, treatment, prognosis, and care related to my physical or mental health to the extent relevant to my claim. I understand that this authorization is voluntary and that I may revoke it at any time by providing written notice, except to the extent action has already been taken in reliance on it. Unless earlier revoked, this authorization shall remain valid for one year from the date of my signature, or until the conclusion of my claim, whichever occurs later*
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