Your referral will receive a call from this number or o 855-380-4400

636-524-0087. Please pass along—safe to answer! f 855-380-4401

sales@vcchc.com

Pre-Qualification Short Form

Please Print Clearly Please fill in ALL INFORMATION completely to better serve you and your clients

CLIENT PRIMARY CONTACT

Name _______________________________________________ Name ____________________________________________

Phone ______________________________________________ Phone ___________________________________________

Email _______________________________________________ Email ____________________________________________

Best Time to Contact ___________________________________ Relationship to Client ________________________________

Choose one: ___ Veteran ___ Surviving Spouse ___ Married Best Time to Contact _________________________________

1. Do you need home care services or need more home care hours? Yes No
2. Are you a Veteran, Spouse of a Veteran, or surviving spouse of a Veteran? Yes No
3. Did the Veteran serve at Least 90 consecutive days of active duty, with at least Yes No
one day during any of the following wartime periods?

*If yes, please World War II 12/07/1941 - 12/31/1946

select applicable Korean War 6/27/1950 - 01/31/1955
wartime period Republic of Vietnam 2/28/1961 - 08/05/1964
Vietnam 8/05/1964 - 05/07/1975
Gulf War 8/02/1990 - TBD (minimum 2 years active duty)

4. Was the Veteran honorably discharged? Yes No

5. Are assets less than $138,489? (excluding 1 car & 1 home) Yes No

Please advise the Veteran, surviving spouse or primary contact that a representative from your
partner Veterans Care Coordination will be calling within 24-48 hours from an 855 area code to
secure additional information.

Referring Organization: Referred by:

Branch Location: Phone:

Email: Alt Phone:

Veterans Care Coordination, LLC is not associated with any government agency. Veterans Care Coordination, LLC cannot offer legal advice or guarantee eligibility
for monetary compensation or the Aid and Attendance Pension. We are a healthcare based organization. Copyright ©2022 Veterans Care Coordination, LLC. All
rights reserved. Veterans Care Coordination® is a registered trademark of Veterans Care Coordination, LLC and/or its affiliates.