Customer Cabinet - Procare Direct Access

ProCare Direct Access – Veteran Case Evaluation Form

Thank you for your service. This form helps us determine how our clinical team can best support your VA Disability or Mental Health Evaluation needs. Your responses are confidential and used only for intake and claim-support planning.

Full Legal Name

First Last

Phone Number

Email Address

City / State/ ZIP

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Current VA Disability Rating

Yes

No

If yes, what is your current combined rating? (If known, please include individual conditions and percentages in the notes section)

%

Prior VA Claim History – Have you ever filed a VA disability claim before?

Yes

No

If yes, what was the most recent outcome?

Approved

Denied

Pending Decision

Appealed / Higher-Level Review

Supplemental Claim Filed

If yes, briefly describe any issue(s) under VA claim:

Consent to Contact and Evaluation Review

By checking this box, I authorize ProCare Direct Access to contact me by phone, text, or email regarding evaluation services, scheduling, and follow-up related to my VA disability or mental-health assessment request.

Signature of Veteran / Applicant:

I understand that this communication does not, by itself, establish a patient-provider relationship or guarantee specific disability rating outcomes.

Date

Preferred Contact Method

Phone

Text

Email

Any