Veteran Intake Form - Battle Scar Claims, LLC

Today's Date *

MM/DD/YYYY

Last Name *

Middle Name *

First Name *

Have you served under a different last name?

List the name you served under.

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Have you ever received separation pay, disability severance pay, or any other lump sum payment from your branch of service? *

If you have received separation pay, disability severance pay, or any other lump sum payment from your branch of service and you are applying for VA Disability, it may impact the amount of your VA disability compensation. The VA typically deducts these lump sum payments from your ongoing disability benefits. It’s essential to provide accurate information about such payments when applying for VA Disability, as it can affect the determination of your eligibility and compensation amount.

Military Occupational Specialty *

This should be numbers and letters.

What was the title of your job? *

Example: Administrative Specialist, Infantry Man, Supply, Fueler, etc…..

Did you have a secondary Military Occupational Specialty?

List it in this filed. Skip this question if it doesn’t apply to your time in service. If you currently receive a VA Rating, do not attached your DD214.

Have you earned an Air Assault, Parachute or Airborne Badge? *

A Parachute Badge, also known as a Parachutist Badge or Airborne Badge, is a military insignia worn by personnel who have completed the necessary training and qualification to conduct parachute jumps.

Branch of Service *

Army
Air Force
Navy
Marines
Coast Guard

Military Service Component *

Active
Reserve
National Guard

How did you enlist? *

Officer
Enlisted

Are you retired? *

Yes
No
In the process

Date of Birth *

Place of Birth (City and State) *

This field is needed if we have to submit a REQUEST PERTAINING TO MILITARY RECORDS on Standard Form 180 online.

VA File Number/ SSN *

Battle Scar Claims understand the importance of safeguarding the privacy of social security numbers (SSNs) and VA File numbers. We are committed to maintaining the confidentiality and integrity of these identifiers and adhere to strict privacy protocols and security practices.

Service Start Date *

Date you entered Active Duty

Service End Date (ETS – Ending Term of Service) *

Date and correct year you completed Active Duty

City and State of Seperation (ETS – Ending Term of Service) *

Specify the city and state where you departed from the military.

Have You Ever Served in the Reserves or the National Guard? *

If yes, which component?

Reserves
National Guard

Service "START" Date ( Skip this question if it doesn't apply to you)

Month, date and year you “BEGAN” your service.

Service "END" Date ( Skip this question if it doesn't apply to you)

Month, date and year you “ENDED” your service.

City and State of Seperation (ETS – Ending Term of Service)

Specify the city and state where you departed from the military.

How you ever been deployed? *

Identify each country below.

Please provide the year in which your deployment took place?

If you have multiple deployments, list each year.

Areas of Deployment

Afghanistan
Djibouti
Somalia
Iraq
World War I or II
Iran
Bosnia
Africa
Kuwait
Bahrain
Qatar
Kazakhstan
Pakistan
Saudi Arabia
Pearl Harbor
Syria
No Deployments

Current Disability Compensate Rating *

0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%

If you are a Veteran rated at 100%, unfortunately we do not provide consulting services.

Do you have a copy of your DD 214 or Discharge Documents? *

Yes
No
Require a Copy

If you have a previous disability rating, this section isn’t a requirement. You are already in VA’s system.

Attachment Document

Click or drag files to this area to upload. You can upload up to 4 files.

Please Attach Discharge Documents

How soon can Battle Scar Claims assist? *

Immediately
1 Week
1 Month

The commencement of services provided by Battle Scar Claims, LLC is dependent on receipt of payment. This questionnaire is intended to gather information to assess how we can be of help, but it does not constitute a legally binding contract agreement.

Do you currently have an "ACTIVE" claim open with Department of Veterans Affairs?

Battle Scar Claims accepts clients on a case-by-case basis for claims currently in progress.

I understand that Battle Scar Claims is not responsible for the appeal deadline specified in my decision letter. It is my responsibility to provide all necessary medical documents to BSC in a timely manner to ensure there is enough time to file my claim. Our objective is to submit claims at least 30 days before the one-year deadline. *

Battle Scar Claims accepts clients on a case-by-case basis for claims currently in progress.

Seperation Pay & Severance Pay *

YES, I TAKE FULLY RESPONSIBILITY FOR MAKING PAYMENT TO BATTLE SCAR CLAIMS, LLC.
NO, I “DO NOT” I TAKE FULLY RESPONSIBILITY FOR MAKING PAYMENT TO BATTLE SCAR CLAIMS, LLC.
I DO NOT REMEMBER BUT I DO UNDERSTAND, IF RETROACTIVE PAYMENT IS MADE, I AM STILL CONTRACTUALLY REQUIRED TO PAY.

Separation pay from the military, also known as severance pay, is a one-time, lump-sum payment made to service members who are involuntarily discharged from the military under specific circumstances. The purpose of separation pay is to provide financial assistance to military personnel as they transition to civilian life, particularly when their military service is terminated prematurely. If you proceed with the contract, knowingly or unknowingly and you are the recipient of Separation or Severance pay, “YOU ARE STILL RESPONSIBLE FOR FULL PAYMENT TO BATTLE SCAR CLAIMS, LLC.”

Are you in possesion of your Military 'Active Duty" Medical Records? *

Military Service Treatment Records (MSTR) are health records created during an individual’s military service or while a veteran was on Active Duty. These records include information about medical examinations, treatments, surgeries, and other healthcare-related details during the time you went to the base or post’s medical treatment facility, commonly referred to as the Troop Medical Clinic (TMC), or “sick call,” or the base hospital.

Do you have access to your VA Medical Records? *

The Department of Veterans Affairs or VA Medical Records refer to health records maintained by the Department of Veterans Affairs (VA) for veterans who have received medical care or services through the VA healthcare system “After Being Discharged From Active Duty.” These records include information about diagnoses, treatments, prescriptions, and other healthcare-related information provided by the VA.

Do you have access to your Civilian Medical Records? *

Civilian Medical Records are health records maintained by non-military healthcare providers in the “Private Sector Using Your Private Insurance.” They include information about medical visits, diagnoses, treatments, prescriptions, and other healthcare-related details received outside of the military and VA healthcare systems.

I understand that it is my responsibility to ensure a Letter of Intent is on file with Department of Veterans Affairs. *

Call 800.827.1000 and notify the Department of Veterans Affairs that you would like to request a Letter of Intent (LOI) to be submitted on your behalf. Monitor your mail for confirmation of this document.

Do you have dependents? *

Spouse
Child /Children
Parent(s)
Single Veteran

A dependent is a person who has a relationship to the military sponsor (Veteran) and is entitled to certain benefits by virtue of that relationship. Certain family members, primarily a spouse, child, stepchild, or legally adopted child, are automatically entitled to dependency status. Other family members may become military dependents under certain conditions and after a special review. Examples include a parent, a parent-in-law, grandparent, grandparent-in-law, grandchild, disabled child over the age of 21, and a brother, sister, niece or nephew for whom the service member has legal guardianship.

I acknowledge that I am accountable for formally requesting the cancellation of a contract with another company, law firm, or entity in writing. I am also responsible of receiving a cancellation notice in writing or by email. I recognize that despite the cancellation of said contract, I remain liable for fulfilling any outstanding payments associated with pending or open claims to the respective organizations. Prior to initiating our assistance, it is required that all claims be finalized and closed. It is imperative that you provide full disclosure of these circumstances to Battle Scar Claims. *

Battle Scar Claims, LLC is NOT an accredited agent, VSO, attorney, or entity recognized by the Department of Veterans Affairs (VA) and is not affiliated with the VA in any way. Veterans may search for and appoint an accredited VSO, Accredited Attorneys or Claims Agent for represenation. Battle Scar Claims is not a law firm, does not have an attorney on staff, and is not licensed to practice law in any jurisdiction or represent clients before The Board of Veterans Appeal. Our team consists of benefit experts who are former service members, bringing a wealth of firsthand experience and specialized knowledge to our clents. We are also partnered with organizations who can assist with more complex claims. *

HIPAA (the Health Insurance Portability and Accountability Act) is a federal law that establishes standards for protecting the privacy and security of individuals' health information. Battle Scar Claims, LLC is compliant with safe handling of healthcare and personal information and understands will abide by internal privacy policy to ensure confidentiality and integrity. Using secured methods for collecting medical records can help prevent unauthorized access, use, or disclosure of this information. Battle Scar Claims is committed to maintaining HIPAA compliance and using secure methods for collecting medical records is important to protect the privacy and security of individuals' health information. *

Veteran's Electronic Signature *

Before submitting any documents on your behalf, we will ensure to provide you with prior notification. If you choose to proceed and select “yes,” you are granting authorization to Battle Scar Claims to include an electronic signature in situations where you are not physically present.

Name of Individual Who Referred You

Battle Scar Claims, LLC would like to express gratitude towards the individual who referred you to our business. We want to acknowledge their effort and contribution to the growth of the business and say THANK YOU!

Confidentiality & Privacy *

Acknowledged!

Maintaining confidentiality & privacy is an important aspect of providing consulting services to our Veterans. It ensures that sensitive information is not disclosed without the Veteran’s consent and it helps build trust and respect between Battle Scar Claims, LLC and our Veterans. Unless explicit permission is granted in writing or email by the veteran, we are not at liberty to discuss or disclose any information with the REFERRER or their SPOUSE.

Battle Scar Claims, LLC have clear policies and procedures in place for handling confidential information and to ensure that all staff members are trained and aware of the importance of maintaining confidentiality.

Signature

Clear Signature

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Battle Scar Claims, LLC

Headquartered in Irving, Texas we’re a disability consulting firm of dedicated professionals who are passionate about helping veterans

Services Provided

Claims Assistance

Navigating VA

Discharge Upgrade

Educating Veterans

Benefits Counseling

Case management

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