Application for Medical Services

Healing Heroes Network arranges medical treatments through its nationwide network of providers at no cost to the veteran. The needed treatment must be the result of an illness or injury incurred or aggravated in the line of duty after September 11th, 2001. Please be prepared to provide your DD Form-214, and/or your last duty orders.

Veteran's Name:*
Gender	MaleFemale
Date of Birth:*
Address:*
City:*
State:*	ALASKA ALABAMA ARKANSAS ARIZONA CALIFORNIA COLORADO CONNECTICUT DISTRICT OF COLUMBIA DELAWARE FLORIDA GEORGIA HAWAII IOWA IDAHO ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANA MASSACHUSETTS MARYLAND MAINE MICHIGAN MINNESOTA MISSOURI MISSISSIPPI MONTANA NORTH CAROLINA NORTH DAKOTA NEBRASKA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEVADA NEW YORK OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VIRGINIA VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING
Zip:*
Home Telephone Number:*
Cell Phone Number:
Email Address:*
Branch of Service:*
Current Military Status:*	Select One Standby Reserve Ready Reserve or Active Individual Reserve National Guard Retired Military-Reg Retired Military-Non Reg Retired Reservist
Date of Injury or Illness:*
Brief description of medical services requested:*

Disclosure: This is a preliminary questionnaire to initiate contact with a Healing Heroes Network representative. Completion of this form does not guarantee that the services requested will be provided. Additional information may be required to determine eligibility. According to HIPAA, you are authorizing HHN to leave a message on your phone, and to access your medical records. HHN will not use your records for any other purpose, or give your information to another party.

Healing America’s troops, one Hero at a time