Services
Mission Critical Clients
Our Company
Careers
Media Center

Join the Program - Interest Form

Let's Talk
Would you prefer to go over this information on the phone? Call us, toll-free at 866.933.VETS.

Thanks for your interest in joining our VA Disability Examinations Management program as a provider. To begin the process, simply fill out the form below and click "Submit Form" when you're through. A member of our team will be in touch. On behalf of our Nation's Veterans, thank you.

GENERAL INFORMATION:
1. Business / Facility Name:
2. Contact First Name:
3. Contact Last Name:
4. E-mail Address:
5. Phone Number:
6. Does your facility have internet access, and are you willing to use it for this program?
7. Do you have in-room computer and internet access?
8. Are you willing to take part in a training course for this program?
9. Is the Provider(s) in your office willing to complete a NACI background check?
10. Is your facility ADA accessibility compliant?
11. Is your facility an OSHA compliant workplace?
12. Are you currently an LHI Provider?
13. What type of provider are you?