Framingham Office
945 Concord Street
Framingham, MA 01701
Tel: 508.620.4525
Fax: 508.459.5060
Worcester Office
255 Park Avenue Suite 410
Worcester, MA 01609
Tel: 508.755.6525
Fax: 508.459.5060

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Elder & Disablility Law Advocates – VA Benefits Pre-qualificatioin Form

* Mandatory Fields
Inquirer Information:
First Name: * Last Name: * Address: *
Home Number: * Email: *
Does the senior plan on living in assisted living or start home care services soon? Yes No
If so, what do you plan on spending per month?
To understand medical expenses, please answer the following:
Type of Care? Home Care Assisted Living
For whom are you requesting information Self Spouse Parent Other
If other please specify
Are you currently in contact with an assisted living or home care agency? Yes No
Tell us about this person:
First Name: Age: Marital Status:
Last Name: Spouse Name: Spouse Age:
Current Address: City: State:
Zip: Residence Type: Do you rent or own
Monthly Payment : Property Value:
Do you plan on living in assisted living soon? If so, what do you plan on spending per month?
War Time Service Questionnaire
Veteran Surviving Spouse of a Veteran
Is the Veteran age 65 or older, or permanently disabled? Is the un-remarried surviving spouse the last spouse of the Veteran at the time of his death?
Did the Veteran serve at least 90 days in active service, with at least 1 day during a wartime period? Did the deceased Veteran serve at least 90 days in active service, with at least 1 day during a wartime period?
Did the Veteran receive an honorable or general discharge? Did the deceased Veteran receive an honorable or general discharge?
Is the Veteran spending at least 75% of his/her monthly income on medical expenses? (including RX, health insurance, home health care, assisted living, and/or nursing home expenses) Is the surviving spouse spending 75% or more of his/her monthly income on medical expenses? (including RX, health insurance, home health care, assisted living and/or nursing home care)?
Health Questionnaire
Medical Diagnosis Alzheimer's Dementia Other
Select the activities of daily living this person requires assistance with:
Dressing Bathing Toileting Transferring Continence Meals Medication Management
Monthly Income / Expense Questionnaire
INCOME VETERAN SPOUSE
Social Security
Pensions
Interest Income
VA Retirement or Disability
Other
Total Monthly Income
EXPENSES
Medicare Part-B
Private Medical Insurance
RX Co-Pays
Doctor Visit Co-Pays
Private or Facility Health Care Costs
VA Health Benefits TRICARE
Total Monthly Expenses
SAVINGS
Checking, Savings, CDs
Stocks, Bonds, Mutual Funds
IRA's
Other
Total Asset/Savings
 
 
Elder & Disability Law Advocates a Worcester MA based law firm specializing in the issues affecting the elderly and people with disabilities. Wills and trusts, estate planning, durable powers of attorney, health care proxies, guardianships, conservatorships, estate administration, probate litigation, MassHealth benefits, medicaid advocacy, veterans benefits, litigation. Serving clients throughout Worcester County and the Central Mass area, Middlesex County and the Boston Metrowest area, and all communities located therein.
 
 
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