VetBenefitsAI - VBAI Kicoff Form

VBAI Intake Form

First Name*

Last Name*

Primary Email*

Branch of military service served.*

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What was your MOS?

Deployed*

Provide current service connected disability rating here.*

Do you have an active claim open?*

Check Yes if working with VSO, DAV (othr veteran advocate) or VA attorney.*

Referred by

AI Consent Statement

Consent for Use of AI in Medical Record Processing

AI Consent Statement

By signing below, I give consent for VetBenefitsAI to use advanced AI tools to process my medical records and related documents solely for the purpose of assisting with my VA claims assessment.

Terms and Conditions Agreement

Agreement to Terms and Conditions

Terms and Conditions Agreement

By signing below, I acknowledge that I have read, understood, and agree to the terms and conditions, privacy policy, and confidentiality agreement outlined by VetBenefitsAI.

Make an Appointment: You will be able to choose from available Appointments on the next step

GREAT! Your appointment with {{appointmentTypeStaffNames[appointmentSelectedCalendar]}} is scheduled!

(Optional and not required) Upload your files here to streamline the process. Files Needed: - In Service Records - Medical Records (Blue Button Download) - Denail Letters - DD214 - Other supporting documents

VBAI Intake Form

AI Consent Statement

Terms and Conditions Agreement

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