VBE Health Care Questionnaire

Health Care Coverage Questionnaire

*This questionnaire is only to be completed as an alternative method of submission to one that was received by mail or email.

(Fields marked with an asterisk '*' are required)

* First Name

* Last Name

* E-Mail Address

* I am already enrolled in VA health care.

* VA health care is my primary health care coverage.

* Medi-Cal is my primary health care coverage.

* Discontinue my Medi-Cal health care coverage.

* I am in a long-term health care facility.

Do you have a service connection disability?

What is your current service connection disability?