ONLINE PATIENT REGISTRATION

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1. Who is completing this online registration form?

I am a U.S. military veteran applying for myself
I am authorized to represent a U.S. military veterans

Note: Relatives, power-of-attorney agents, or lawyers representing veterans submitting this application must provide supporting documents at the time of the patient intake interview.

2(a). Type of Patient

2(b). Patient Gender

2(c). Patient's Height

(e.g., 5-10)

(d). Patient's Weight (lbs.)

3(a). Current Status of Patient

Experiencing serious pain from injury or illness
A resident or visitor of FSM, RMI, or Palau at present
Needing mental health treatment (e.g., nervous breakdown)
Needing a medical prescription refill
Seeking urgent care for a new health issue
Experiencing an emergency (e.g., severe bleeding, heart attack)
Has an Electronic Health Record ID No. (FSM Residents Only)

(please select all that apply)

3(b). Your EHR ID No. (FSM Residents Only)

(please specify if known)

4. Name of Veteran/Patient

First

Middle

Last

5. Date of Birth

(MM/DD/YYYY)

6. Physical Address

7. City/Town

8. State/Province

9. Zip/Postal Code

10. Country

11. Name of Country (optional)

(Please specify your country if other than RMI, FSM, or ROP.)

12. Is your mailing address different than the address above?

13. Alternative Mailing Address (Street, City/Town, Postal/Zip Code)

(Optional. Please skip if not applicable)

14. Alternative Mailing Address (Country)

(Optional. Please skip if not applicable)

15. Email Address

Confirm Email

16. Veteran Phone Contact

(Please include your country area code; e.g., Micronesia +691 123456)

18. SSN or ITIN

I have a Social Security Number
I do not have a Social Security Number
I have a VA member ID (VHIC)
I have a VA member ID (VHIC), but do not have a SSN/ITIN

(Please select all that apply)

19. Does/Did the Veteran live or travel outside of the U.S. more than 30 days within the last 2 years?

20. Your VA Disability Rating

22. Your last eye examination

23. Vision care appointment request

(Please specify if you wish to be scheduled for an eyecare appointment)

24. Last visit with a dentist

25. Dental care appointment request

(Please specify if you wish to be scheduled for an dental care appointment)

27. Deceased Veterans (if applicable)

My late spouse was a military veteran
My parent was a military veteran
My family or me paid for the burial or funeral services for a deceased veteran
I have never received a Survivors Pension
My family or me paid for the health services for a deceased veteran in my family within the last 2 years
At no time did the VA reimburse me for burial or funeral expenses for a deceased veteran in my family

Note: Only persons completing this application for a deceased veteran should complete this section.

28. Are you interested in VA financial aid programs for housing or home upgrades?

If you have a service-connected disability, you may be able to get an SAH grant if you’re using the grant money to buy, build, or change your permanent home (a home you plan to live in for a long time) and you meet both of these requirements.

29. Are you interested in VA financial aid programs education and workforce training?

Veteran Readiness and Employment (VR&E) helps veterans with service-connected disabilities and employment handicaps prepare for, find and keep suitable jobs. For veterans with service-connected disabilities so severe that they cannot immediately consider work, VR&E offers services to improve their ability to live as independently as possible. This program includes financial aid for education and training at vocational and post-secondary colleges and schools (e.g., online courses and in-person classes). Spouses and dependents of disabled veteran-households are eligible for this program, also.

30. Within the last 2 years have you visited a VA Health facility?

31. Where was the VA Health facility that provided your care? (if applicable)

33. Do you have an allergy to any food or medication?

34. Name(s) of Current Medication(s) (if applicable)

(Insert a comma between each medication, if more than one)

36. I would like to join the SNP Veterans Health Member Program for my spouse, child, or myself.

NOTE: This health services program is provided to COFA military veterans without a non-service-connected disability approved under the VA Foreign Medical Program. This health services membership plan covers veterans, and their spouses, and children or dependents within veteran household. Your intake nurse can provide you more details at your first contact appointment.

37. Additional Information (optional)

(e.g., urgent care or immediate surgical needs; prescription refills; name of VHA primary care physician or social worker)

38. Name of Applicant

Please specify the name of the "Veteran" completing this medical patient questionnaire. By submitting this form, you agree that you are a U.S. military veteran (or person authorized to act on behalf of a U.S. military veteran) who is applying for health services through SNP Veterans Medical Center & Health Systems Ltd., an authorized provided for Veterans Recovery Network PBC ("VRN") under respective financial aid resources and grant programs offered by the United States Department of Veterans Affairs (the "VA"). Thereby, the Veteran authorizes VRN to review and process this questionnaire to check eligibility or enable the Veteran's access to such health services covered by the VA, in addition to other health benefits offered by VRN. VRN keeps all information submitted by the Veteran hereto confidential and does not share information with third parties that are beyond the authority and scope of the VA, VRN, or affiliated government agencies (e.g., Department of Health).

Checkboxes

I AGREE that the information provided here is true and correct to the best of my knowledge, and approve of the submission of this information to VRN only for internal use or communication with the VA.