• Veteran Intake Form

    Thank you for choosing Luna Fidelis Wellness. Please complete the information below and upload the records relevant to the condition(s) you would like reviewed. Providing complete and accurate records will help facilitate a comprehensive review of your medical history and supporting evidence.
  • Date of Birth*
     - -
  • Employment
  • Service Start Date*
     - -
  • Service End Date*
     - -

  • VA Disability Information

  • Is condition diagnosed*
  • Was it previously denied (If so, please upload below).*

  • Upload Your Records

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  • Upload File
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  • Records Review Acknowledgment/Disclaimer

    By submitting this form and my supporting records, I acknowledge and understand the following:

  • Purpose of Review
    I understand that the information and records I provide to Luna Fidelis Wellness will be reviewed for the purpose of conducting an independent medical evaluation and determining whether the available medical evidence supports an independent medical opinion related to my VA disability claim.

    No Guarantee of a Medical Opinion
    I understand that submission of records and completion of a consultation do not guarantee that a Nexus letter, rebuttal opinion, or other favorable medical opinion can be provided. Any medical opinion issued by Luna Fidelis Wellness must be supported by the available medical evidence, applicable clinical standards, and the provider's independent professional judgment.

    No Guarantee of VA Claim Outcome
    I understand that an independent medical opinion does not guarantee approval of a VA disability claim, a particular disability rating, or any other outcome. Decisions regarding service connection, disability ratings, and VA benefits are made solely by the U.S. Department of Veterans Affairs.

    Independent Evaluation — No Ongoing Treatment Relationship
    I understand that services provided by Luna Fidelis Wellness are limited to independent medical evaluation, records review, and, when medically supportable, preparation of an independent medical opinion. These services do not include ongoing medical treatment, primary care, medication management, prescribing, emergency care, or ongoing management of my medical conditions.

    Accuracy and Completeness of Records
    I certify that, to the best of my knowledge, the information I provide is accurate and that the records submitted are authentic and relevant to my requested review. I understand that incomplete, inaccurate, or missing information may affect the ability to complete an appropriate medical evaluation or provide a medical opinion.

    Medical Care
    I understand that Luna Fidelis Wellness's independent evaluation is not a substitute for medical care from my treating healthcare providers. Questions or concerns regarding diagnosis, treatment, medications, or changes in my health should be addressed with my treating healthcare provider.

    Acknowledgment
    By signing below, I confirm that I have read, understand, and acknowledge the information above.

  • Date*
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