HERO Application

Healing Heroes Network provides financial assistance and arrangements for 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 in Iraq or Afghanistan after September 11, 2001.

You must provide HHN with a copy of your DD Form-214 and/or your last duty orders before we can complete your application process. You can upload them now for faster processing.

* Required Information

Veteran's First Name (*)	Please type in your first name.
Veteran's Last Name (*)	Please type in your last name.
Gender (*)	MaleFemale Please select your gender.
Date of Birth (*)	Please type in your date of birth.
Street Address (*)	Please type in your street address.
City (*)	Please type in your city.
State (*)	--Please Select--AKALARAZCACODCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Please select your state.
ZIP Code (*)	Please type in your ZIP code.
Phone (*)	Please type in your phone number.
E-Mail (*)	is not a valid e-mail address.
Branch of Service (*)	Please type in your Branch of Service.
Current Military Status (*)	--Please Select--ActiveRetiredActive GuardRetired GuardActive ReserveRetired Reserve Please type in your current Military Status.
Date of Injury or Illness (Must be on or after 9/11/01) (*)	Please type in your date of injury or illness.
Where were you injured? (*)	Please tell us where you were injured.
How were you injured? (*)	Please tell us how you were injured.
Description of Medical Services Requested (*)	Please give a description of the medical services requested.
Description of Medical History Since Your Injury (Treatments, Medications, etc...) (*)	Please give a description of your medical history since your injury.
Upload Your DD Form-214
Upload Your Last Duty Orders
How did you hear about HHN? (*)	Please tell us how you heard about us.
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.
Security Verification (*)	Please enter the 4 letter security code you see into the box.