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VBE Health Care Questionnaire
Page Content
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.
Select one
No
Yes
*
VA health care is my primary health care coverage.
Select one
No
Yes
*
Medi-Cal is my primary health care coverage.
Select one
No
Yes
*
Discontinue my Medi-Cal health care coverage.
Select one
No
Yes
*
I am in a long-term health care facility.
Select one
No
Yes
Do you have a service connection disability?
Select one
No
Yes
What is your current service connection disability?
Select one
0%
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30%
40%
50%
60%
70%
80%
90%
100%
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VBE Health Care Questionnaire