VAFMS MEDICAL SERVICES

VA FOREIN Medical Services E.I.N -301168216 R.N.C-1-31-607748

Secure Fax Number:980.216.6020 Secure Fax Number:980.216.6020

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VAFMS FORMS

Name *

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Last

Date *

Date of Birth *

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Address *

Address Line 1

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Phone *

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Age

Gender *

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Email *

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Subscriber Name and ID Number *

DOB *

Group No. *

Health concerns in order of importance:

Current Physicians

Physician Name *

Speciality *

Phone *

Physician Name

Speciality

Phone

Physician Name

Speciality

Phone

Significant Health History *

Allergies (medication, food, environmental) *

Current Medications/Supplements: What are you taking the medication for ( I.E back Pain ) *

Other Comments

Have you ever applied for Service Connection through VBA ? *

Are You Service Connected *

At What % ? *

Date of Service Connection *

What Conditions are you service Connected for? *

Do you want help to start your Claim with VBA? *

Can we provide your information to Our Claims Repetitive to assist you in your claim? *

We can still assist you with medical Treatment and paperwork that you might need for your claim. *

Signature *

Date *

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High quality care for all Veterans in need

For assistance with Medical issues, or other urgent needs, we’re here to help! It’s not too good to be true. It’s the way healthcare should be at VAFMS! The Best Medical Care in the caribbean!

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We are the largest Medical Facility in the Caribbean taking care of the Men and Women who served our Country!

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Puerto Plata

809-320-7735
help@vafms.org
Calle 26 de agosto
frente al colegio Montessori Puerto Plata

Santo Domingo

809 – 683 – 4281
help@vafms.org
Calle Georgilio Mella Chavier 10
Santo Domingo

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