Veteran's Eligibility Questionnaire

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Veteran's Home Care Eligibility Questionnaire

a) Contact Info:

* Indicates required field

Name of Inquirer *

First

Last

Please enter the name of the person asking about the program.

Name of Veteran or Surviving Spouse *

First

Last

Select One *

Phone Number *

Email *

Please enter the eMail of the person with whom we can discuss the eligibility for the program.

Comment *

b) Eligibility Questions:

1. Was the Veteran discharged honorably? *

Yes No

2. Did the Veteran serve at least 90 consecutive days of active duty, with at least 1 day during a period of war? *

WW II (12/07/1941 - 12/31/1946 Korea (06/27/1950 - 01/31/1955 Vietnam (02/28/1961 - 05/07/1975) Gulf War (08/02/1990 - TBD - must be active duty for 2 years)

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Choose One *

Yes No

Please check 'yes' or 'no'.

3. If surviving spouse, were you married to the veteran at the time of death? *

Yes No N/A

4. If surviving spouse, did you remain unmarried after the Veteran's death? *

Yes No N/A

Please check 'yes' or 'no' for surviving spouses, 'n/a" for Veteran.

5. Is there a need for assistance with the activities of daily living (Bathing, dressing, housekeeping, toileting, cooking, grocery shopping, etc.) *

Yes No

6. Are the Veteran's assets less than $127,061 (excluding car and home) *

Yes No

Please check the appropriate level of assets.

Select One *

7. Is the Veteran or surviving spouse currently receiving an VA benefits? *

Yes No

8. Are there already any home care services being provided? *

Yes No

Please check 'yes' or 'no'.

9. Is Assisted Living or Nursing Home care being considered within the next 60-90 days? *

Yes No

Please check 'yes' or 'no'.

Please note that by hitting submit you are agreeing to being contacted by Alpine Homecare / our authorized representative to discuss your eligibility for the program. You will typically be contacted within 24-48 hours.

Submit

Alpine Homecare - 10200 E. Girard, Bld. A, Suite 200 - Denver, Co 80231 - T. (303) 309 6202 / Fax (303) 309-6206 - [email protected]