Please answer all questions fully to the best of your ability. Some questions may not apply to your specific case. In that situation, simply put ‘N/A’ as your entry. If you do not know the answer to a particular question, you should state ‘Unknown' as your entry.
Please list the names of all known prescribed medications that Claimant took over the course of their lifetime, along with the approximate dates of use. (Ex: Zantac, 2018 - Present)
Please list the names of all known doctors and medical facilities that Claimant treated with over the course of their lifetime, along with the approximate dates of treatment. (Ex: Dr. John Doe, Montgomery Clinic, Chemotherapy 2015-2017)
Please provide any other facts or information that you believe may be relevant to this case.
If you have copies of Claimant's DD214s, Medical Records, Death Certificate (If Applicable), Last Will (If Applicable), or other relevant documents, please upload them here. If you are unable to upload, please email the files to email@example.com or mail physical copies to our Mobile, AL office located at 1 St. Louis St., Suite 1002, Mobile, AL 36602.
Max. file size: 256 MB.
Drop files here or