Referral Phon e Number _________________
Information Regarding Referrals to Signal
The “Aid and Attendance” pension is a benefit for non-service related disabilities, available to veterans or their surviving
spouses who may be eligible. In order to be eligible for the pension:
The veteran must have served at least 90 days active duty in the military, with at least one day during wartime. (Persian Gulf
War veterans must have two years of active duty or the full period for which they were called for active duty.)
The applicant must be at least 60% housebound (no longer driving), which will require certification by a licensed
physician.
The applicant must meet certain income and asset limits.
Applicants will need the following documentation to begin the application process:
Discharge papers (DD214) – We can assist in getting these documents through NARA
Death Certificate with cause of death (if client is a surviving spouse)
Marriage Certificate or other proof of marriage, including date (if client is a married veteran or surviving spouse)
Please inform the prospective client that Signal Health Group will need to ask personal questions regarding income and assets in
order to prepare the application to the VA. Answers to all questions, including those that are financially related, will be kept confidential
and will only be used to complete the application.
If the prospective client is unable or unwilling to answer income or asset-related questions, Signal Health Group cannot assist him/her in
applying for the “Aid and Attendance” VA pension.
Agency Name and Branch/Location Needed
Please indicate your Agency ’s Name and Branch/Location, especially in franchise situations. Forms without this information will take longer
to process.
Example: Franchise Home Care—Houston, TX
Applicant Zip Code Needed
Please indicate the Applicant’s Zip Code. Forms without this information will take longer to process.
Options for Sending Referrals
Call ________________ and talk with an enrollment specialist. Or, use this form and fax to+++++++++++++ or email it to us at referrals@
signalhg.com or send us your referral online at www.signalhg.com
Signal Health Group and their Franchises are not part of any government agency and are not affiliated with the Department of Veterans Affairs.