Disability Evaluation Intake Form — Valor Medical Evaluations

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Personal Information

Please use your full legal name and contact details exactly as they appear on your insurance or legal documents.

First Name *

Last Name *

Middle Name

Date of Birth *

Gender / Sex Assigned at Birth

Preferred Language

Do you need a language interpreter?

No Yes

Social Security # (Last 4 digits only) Used only for claim record matching

Primary Phone *

Secondary / Alternate Phone

Email Address *

Home Street Address *

City *

State

ZIP Code

Emergency Contact

Emergency Contact Name

Relationship to You

Emergency Contact Phone

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Claim & Legal Information

Tell us about the nature of your claim and any legal or insurance parties involved.

Type of Evaluation Requested *

Referral Source *

Insurance Carrier / Company

Policy / Claim Number

Date of Injury / Onset of Disability *

How did the injury / condition occur?

Please describe in detail how your injury or condition occurred *

Attorney Information (if represented)

Attorney Name / Law Firm

Attorney Phone

Attorney Email

Case / File Number

Employer Information (Workers' Comp claims)

Employer Name at Time of Injury

Your Job Title

Employer Phone

Were you represented by a union?

No Yes

Has a prior disability rating been assigned?

No Yes — Provide details below

Prior Rating Details

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Medical History

Provide a complete medical history. More detail leads to a more thorough and accurate evaluation report.

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Current Symptoms & Condition

Help us understand your current symptoms in detail — this directly informs the evaluation.

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Impact on Daily Life

Rate your ability to perform everyday activities. This helps evaluators understand the real-world effects of your condition.

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Work History & Employment

Information about your employment helps determine the functional impact of your disability on your capacity to work.

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Military Service History

This section helps document your service-connected conditions and military background for a thorough VA or disability evaluation.

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Supporting Documents

Upload any medical records, reports, or documents to support your evaluation. All uploads are securely encrypted.

📌 Tip: The more records you provide, the more thorough and accurate your evaluation report will be. You may also bring physical copies to your appointment.

Upload Medical Records & Imaging Reports

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Click to select files or drag and drop

Medical records, X-rays, MRI reports, lab results — PDF, JPG, PNG

Upload Prior IME or Evaluation Reports

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Click to select files

Prior IME reports, functional capacity evaluations — PDF

Upload Attorney, Claim, or Insurance Documents (optional)

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Click to select files

Referral letters, claim correspondence — PDF

Anything else you would like the evaluator to know?

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Consent & Authorization

Please read and sign each authorization to complete your intake. All signatures are legally binding.

⚠️ Please read each section carefully before checking. Your typed name constitutes a legal electronic signature.

1. Authorization to Conduct Medical Evaluation
I authorize Valor Medical Evaluations and its designated physicians to conduct an independent medical evaluation as requested by the referring party. I understand this evaluating physician is not acting as my treating physician and that the evaluation is for the purpose of providing an independent medical opinion.

I authorize and consent to the medical evaluation *

2. Authorization to Release Medical Records
I authorize my treating physicians, hospitals, clinics, and other healthcare providers to release medical records relevant to this evaluation to Valor Medical Evaluations and to the requesting party (insurance company, attorney, or employer, as applicable).

I authorize release of my relevant medical records *

3. HIPAA Privacy Notice Acknowledgment
I acknowledge that I have been informed of Valor Medical Evaluations' HIPAA Privacy Practices, including how my health information may be used and disclosed in the context of this evaluation. I understand my rights regarding my protected health information.

I acknowledge the HIPAA Privacy Notice *

4. SMS & Email Communication Consent (Optional)
I consent to receive appointment reminders, status updates, and communications via text message (SMS) and email from Valor Medical Evaluations. Message and data rates may apply. You may reply STOP to opt out of SMS at any time.

I consent to SMS and email communications (optional)

Electronic Signature — Type your full legal name * By typing your name, you confirm that all information provided in this form is true and accurate to the best of your knowledge, under penalty of perjury.

Date *

Relationship to Patient

⚕️ Valor Medical Evaluations

Personal Information

Claim & Legal Information

Medical History

Current Symptoms & Condition

Impact on Daily Life

Work History & Employment

Military Service History

Supporting Documents

Consent & Authorization

Your Intake Form Has Been Submitted!