Veteran-Patient Notice of Acknowledgment Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Legal Name of Veteran *FirstLastAre you a military veteran from one of the Freely Associated States? *Select OneYesNoDate of Birth *(MM/DD/YYYY)Do you believe you were treated unfair or less-than equal as a COFA military veteran compared to other military veterans residing in the U.S.? *Select OneYesNoIf you answered yes above, when did you begin to feel this way?Select OneLess than a year agoMore than a year agoMore than five years agoLess than 1 year from when I left militaryI cannot remember(optional)Veteran-Patient Signature. *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).DatePATIENT ACKNOWLEDGMENT *Yes, 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.No, I do not agree with the Patient Acknowledgment.Submit
