Aid & Attendance Form

Complete this form to begin your Aid & Attendance benefit evaluation. Our medical team will review your information and provide comprehensive documentation.

Service Pricing

Aid & Attendance (Form 21-2680) Evaluation

$2,000

7-10 business days

Rush: +$500 (36-48 hours)

Service Type

What service do you need? *

Veteran Information

Veteran's Full Name *

Social Security Number *

Date of Birth *

Phone Number *

Email Address *

Contact Person (if different from veteran)

Contact Name

Relationship to Veteran

Contact Phone

Contact Email

Medical Information

Primary Diagnosis/Condition *

Secondary Diagnoses

Current Medications

Primary Physician Name

Physician Phone

Last Medical Examination Date

Activities of Daily Living Assessment

Please indicate the level of assistance needed for each activity:

Bathing/Showering *

Dressing/Undressing *

Eating/Feeding *

Toileting *

Walking/Mobility *

Transferring (bed to chair) *

Continence Control *

Care Requirements

Supervision Needed *

Hours of Assistance Needed Daily

Current Caregiver Information

Additional Information

Additional Details

Rush Service (+$500 USD for 36-48 hour delivery)

Important Notice

• All information provided will be kept confidential and HIPAA compliant
• A physician evaluation may be required as part of the assessment
• Supporting medical records should be uploaded after form submission
• Processing time is 7-10 business days (36-48 hours for rush service)