Disability Benefits Questionnaire


Items Selected

Pay with Credit Card

Payment Terms & Conditions

You agree to pay all fees for your Veterans Benefits Evaluations, LLC Services in accordance with the fees, charges, and payment terms in effect at the time a fee or charge is due and payable. All pricing terms are confidential, and you agree not to disclose them to any third party. You should be aware that Veterans Benefits Evaluations, LLC may use a third-party payment processor to process fees. The processing of payments or credits in connection with your use of Veterans Benefits Evaluations, LLC services will be subject to the terms, conditions, and privacy policies of the payment processor and your credit card issuer in addition to this Payment Terms Agreement. Veterans Benefits Evaluations, LLC is not responsible for any errors by the Payment Processor or your credit card issuer. You understand and agree that for services provided on an appointment basis, if you fail to properly cancel a scheduled appointment at least 72 hours in advance of the appointment or if you fail to attend the appointment, you will be responsible for a missed appointment fee. (See “Missed Appointment Policy”) You understand that Expert Medical Opinions, Nexus Letters, and/or any other requested documentation will only be provided to you by Veterans Benefits Evaluations, LLC after full payment of the fee has been received.

Refund/Missed Appointment Policy

You understand that once a provider has begun working on your documents, that no refunds will be issued. You understand and agree that for services provided on an appointment basis, if you fail to properly cancel a scheduled appointment at least 72 hours in advance of the appointment or if you fail to attend the appointment, you will be responsible for a missed appointment fee of $100.

Privacy Practices

I understand that Veterans Benefits Evaluations, LLC may need to use and disclose information about my health or medical problems for the purpose of arranging, conducting, or referring for my treatments, for obtaining payment for the services rendered to me and for the operations of the practice. I consent to the use of my information for the purposes of treatment, payment and healthcare operations.

Veterans Benefits Evaluations, LLC reserves the right to modify the privacy practices outlined in the notice.

HIPAA Waivers & Disclaimers

a) Patient acknowledges that neither Group nor Physician guarantees that communications with Physician using electronic mail (“e-mail”), facsimile, video chat, instant messaging, and cellular telephone are secure or confidential methods of communications. Accordingly, Patient expressly waives Group’s and Physician’s obligations under the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. § 1320d et seq.), as amended by the Health Information Technology for Economic and Clinical Health Act of 2009, and all rules and regulations promulgated thereunder (collectively, “HIPAA”), and other state and federal laws and regulations applicable to the use, maintenance, and disclosure of patient-related information, to guarantee confidentiality with respect to correspondence using such means of communication. Patients acknowledge that all such communications may become a part of Patient’s medical records maintained by Physicians. (b) By providing Patient’s email address to Physician, Patient authorizes Physician to communicate with Patient by email regarding Patient’s “protected health information” (“PHI”) (as defined under HIPAA) and Patient understands and agrees to the following: E-mail is not necessarily a secure medium for sending or receiving PHI and, accordingly, any third party may gain access to such PHI. Although Group and Physician will make all reasonable efforts to keep e-mail communications confidential and secure, neither Group nor Physician can assure or guarantee the absolute confidentiality of such e-mail communications. Patient acknowledges and agrees that Physician and Group, along with their assignments, will be entitled to use any data, discoveries, results, improvements, or other information resulting from the Services for any lawful purpose whatsoever, including, but not limited to, internal research, academic or other publications or commercial purposes. All data will be kept on a Cloud-Based system that is password-protected and accessible to the staff at Veterans Benefits Evaluations, LLC and the independent medical professionals working with Veterans Benefits Evaluations, LLC.

Consent to Patient Medical Records

*I hereby give my express permission to Veterans Benefits Evaluations, LLC and the independent medical professionals who may need to obtain and access all of my medical records for VA disability examination purposes only. I understand that my personal and medical information will be stored on a password-protected secure cloud service .

Client Obligations.

I understand that I must cooperate and respond promptly to any reasonable requests from Veterans Benefits Evaluations or the healthcare professionals contracted by the Veterans Benefits Evaluations for instructions, information, or documentation required by the Service Provider or the Contractor to provide the Services. I shall take all necessary steps to prevent any delays in Service Provider’s provision of the Services.

I acknowledge that Veterans Benefits Evaluations, LLC is in the business of providing educational and other support services to United States’ Veterans (collectively “Veterans”) who are seeking information regarding various benefits and other forms of assistance which may be available to them as a result of their military service (collectively “Veteran’s Services”);

WHEREAS, a component of the Veteran Services is the provision to Veterans of access to medical professionals who can assist with the provision of medical evaluations required in support of certain benefits requests;

I understand that Veterans Benefits Evaluations is NOT an “accredited” or “recognized” Veteran Service Organization (VSO), claims agent, claims attorney, or entity recognized by the Department of Veterans Affairs (VA). Veterans Benefits Evaluations is not affiliated with the VA in any way; and I hereby understand that Veterans Benefits Evaluations does NOT assist Clients with the preparation, presentation, and prosecution of VA disability claims for VA benefits nor does Veterans Benefits Evaluations provide legal advice.

I understands that I shall prepare and file my own claim (and should consider doing so, utilizing free government websites such as ebenefits.va.gov, va.gov), or work with an accredited VSO, VA claims agent, or VA claims attorney (many of which offer services for FREE).

I hereby understand that Veterans Benefits Evaluations, LLC does not guarantee service-connection or increase of any of my VA disability ratings using their services nor their website. Determination of VA disability benefits is made solely by the Department of Veterans Affairs and not by Veterans Benefits Evaluations. As such, Veterans Benefits Evaluations is not responsible and cannot be held liable for the VA disability benefits for which a veteran may be eligible.

Veterans Benefits Evaluations Acknowledgement and Release


1. In connection with my request for evaluation services, I, as evidenced by my acknowledge below, am executing this Acknowledgement and Release regarding the evaluation services and access thereto to be provided to me.

2. I understand that Veterans Benefits Evaluations (“VBE”) provides access for veterans to evaluation services in connection with benefits requests made or to be made of the Veterans Administration. VBE does not provide the evaluation services, but rather assists with the provision of access to medical professionals qualified to make the necessary evaluations.

3. I further understand that any medical professional providing evaluation services (the “Evaluator”) relating to my individual request for an evaluation is not providing medical services of any sort to me personally and, furthermore, no doctor-patient relationship is created by virtue of my request for evaluation services or any medical professional’s provision of such evaluation services

4. I hereby release the Evaluator and VBE from any and all claims, losses, damages, or causes of action which may be brought against him/her/it as a result of my request for evaluation services and I agree that I shall not bring any such cause of action against the evaluator or VBE as a result of the Evaluator’s conclusions regarding my evaluation or VBE’s provision of access to the evaluation services being requested by me.

5. This Acknowledgement shall be governed by the laws of the State of Florida without regard to its conflicts of law principles.

6. I have had the opportunity to review this Acknowledgement and Release with legal counsel of my choosing and have either declined to obtain such review or have obtained legal review and am satisfied that I understand the terms and provisions contained in this Acknowledgment and Release.

Your order is being processed. This may take up to 1 minute.
Please don’t close the browser window.

What is Disability Benefits Questionnaire?

Disability Benefits Questionnaires (DBQs) are downloadable forms created by the VA for veterans to collect and record relevant medical information in the evaluation process of their VA disability claims.
The DBQs were designed to answer questions related to the disability Veterans are claiming a rating for i.e. symptoms, severity, causes and connections of one disability to another existing disability.

Check your Eligibility Here

1. What is the condition you are filling this DBQ out for?

We currently only offer the DBQs listed. If you have any questions please send us an email.

Scroll to Top

Before You Go!

Sign up for a FREE no-commitment, consultation to discuss your current disability claim, and find out if our medical experts can assist you in getting an additional increase in your disability.