Referrals

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Veterans Care Coordination™ assists Veterans, surviving spouses, and their families with navigating options for starting home care to support independence and aging in place.

Complete this online referral form to refer a wartime Veteran or surviving spouse in need of home care to Veterans Care Coordination™. Our team will reach out to explore how we can help.

For Assistance -
Use Qualification/Referral Form Below

Or Call 855-380-4400

Download Our Referral Form

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Pre-Qualification Referral Form

Please fill in all information completely to better serve you and your clients. Must be a wartime Veteran or surviving spouse in need of home care.

Client Information

Client Name*
Choose One:*

Primary Contact

Primary Contact Name

Do they already receive home care services?
Do they currently receive any income from the VA?
*If the Veteran is currently receiving income from the VA it cannot be over 70% disability compensation.
1.) Need assistance with ADL’s OR diagnosed with dementia or legally blind?
2.) Was the Veteran honorably discharged from their military service?
3.) Are their assets less than $163,699 excluding one house and one car?
4.) Did the Veteran serve at Least 90 consecutive days of active duty, with at least one day during any of the following wartime periods?
*If yes, please select applicable wartime period.

You must answer ‘yes’ to the last four questions to be referred for Pension with Aid & Attendance.

Please remind the client to expect a call from VCC within the next 24 to 48 hours from a 636 area code.

Referred By

Name*

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