SAVE A VET APPLICATION FOR MEDICAL CARE
Section 1 - General Information

Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years, for concealing a material fact or making a materially false statement (See 18 U.S.C. 1001)

1.VETERAN’S NAME:

2.OTHER NAMES USED:

3.MOTHER’S MAIDEN NAME

4.GENDER

5.RACE   

(Information required for statistical purposes only) 
(You may check more than one)

6.RELIGION   

7.PLACE OF BIRTH         

8.DATE OF BIRTH    

9.SOCIAL SECURITY NUMBER (last 4 digits)

10.HOME PHONE NUMBER (Include area code)
10-2.CELL / OTHER PHONE NUMBER:

11.E- MAIL ADDRESS   

12.PERMANENT STREET ADDRESS    

12-2. CIty  

13.STATE  

14.ZIP CODE    

15.COUNTY       

16.CURRENT MARITAL STATUS  (Check one)

17. NAME , RELATIONSHIP, CONTACT INFORMATION OF NEXT OF KIN
17-1. NAME
17-2. RELATIONSHIP
17-3. PHONE
17-4. ADDRESS

18. NAME, RELATIONSHIP, CONTACT INFORMATION OF EMERGENCY CONTACT
18-1. NAME
18-2. RELATIONSHIP
18-3. PHONE
18-4. ADDRESS

19. TYPE OF CARE APPLIED FOR  
(You may check more than one)

20. HAVE YOU BEEN SEEN BY A VA HEALTH CARE FACILITY?
21. NAME, LOCATION AND PHONE OF REFERRING PHYSICIAN  (IF APPLICABLE)

22. DO YOU NEED A PHYSICIAN REFERRAL AS SOON AS POSSIBlE? 

23. EXISTING CLAIM NUMBERS 

Section 2 - Insurance Information
Veteran's Name
Social Security Number (last 4)
1. ARE YOU COVERED BY HEALTH INSURANCE
2. NAME OF POLICY HOLDER
3. POLICY NUMBER
4. GROUP NUMBER
6. CURRENTLY ON MEDICAID
ELIGIBLE FOR MEDICAID:
7. CURRENTLY ON MEDICARE:
ELIGIBLE FOR MEDICARE:
8. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE - PART A
8a. EFFECTIVE DATE (mm/dd/yyyy)
9. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE - PART B
9a. EFFECTIVE DATE (mm/dd/yyyy)
10. NAME EXACTLY AS IT APPEARS ON YOUR MEDICARE CARD
11. MEDICARE CLAIM NUMBER
12. IF NEED FOR CARE IS DUE TO ONTHE JOB INJURY, BRIEFLY DESCRIBE:
13. IF NEED FOR CARE IS DUE TO AN ACCIDENT, BRIEFLY DESCRIBE:
SECTION 3 - Employment Information
1. Veteran employment
1a. NAME AND LOCATION OF CURRENT OF LAST EMPLOYER IF RETIRED
2. SPOUSE EMPLOYMENT

(mm/dd/yyyy)
2a.NAME AND LOCATION OF CURRENT OF LAST EMPLOYER IF RETIRED
SECTION 4 - Military Service Information
1. LAST BRANCH OF SERVICE
1a. LAST ENTRY DATE
1b. LAST DISCHARGE DATE
1c. DISCHARGE TYPE
1d. MILITARY SERVICE NUMBER
Check Yes or No
A. ARE YOU A PURPLE HEART AWARE RECIPIENT
Yes No
B. ARE YOU A FORMER PRISONER OF WAR?
Yes No
C. WERE YOU EXPOSED TO RADIATION WHILE IN THE MILITARY
Yes No
D. WERE YOU EXPOSED TO AGENT ORANGE WHILE SERVING IN VIETNAM?
Yes No
E. DO YOU NEED CARE OF CONDITIONS POTENTIALLY RELATED TO SERVICE IN SW ASIA DURING THE GULF WAR?
Yes No
F. WERE YOU EXPOSED TO MULTIPLE EXPLOSIVE DEVICES OR TANK DUTY?
Yes No
G. DID YOU SERVE IN COMBAT AFTER 11/11/1998
Yes No
H. DID YOU RECEIVE NOSE AND THROAT RADIUM TREATMENTS WHILE IN THE MILITARY?
Yes No
I. DO YOU HAVE A SPINAL CORD INJURY?
Yes No
J. WAS YOUR DISCHARGE FROM THE MILITARY FOR A DISABILITY INCURRED ORAGGRAVATED IN THE LINE OF DUTY?
Yes No
J1. ARE YOU RECEIVING DISABILITY RETIREMENT PAY INSTEAD OF VA COMPENSATION?
Yes No
K. DO YOU HAVE A VA SERVICE-CONNECTED RATING?
Yes No
K1. IF YES, WHAT IS YOUR RATED PERCENTRAGE?
Yes No