FREE ELIGIBILITY ASSESSMENT See If You May Qualify for Care & Benefits Complete a short assessment to help our team understand your situation. We’ll review your information and guide you through the next step. ELIGIBILITY ASSESSMENT FORM First Name(Required)Last Name(Required)Email(Required) Phone Number(Required)City(Required)Are you a current or former energy worker? Yes No Do you have a White Card? Yes No Are you currently receiving home health care from another company Yes No Are you pleased with your care? Yes No Have you filed a claim before and been denied? Yes No Do you have a pending claim? Yes No Have you been diagnosed with a chronic illness? Yes No Message