Consultation Form

Please take a moment to fill out the form and Dr. Miller will contact you within 48 hours.

First name*

Last name*

Email*

State of Residence*

Phone

How would you like us to contact you?

Phone call

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Which services are you interested in? (Check all that apply.)

Disability Benefits Questionnaire (DBQ) with Independent Mental Health Exam

Nexus Letter

TDIU Letter

What is the disability you are claiming? (e.g. depression, anxiety, PTSD, sleep apnea...)

Is this condition:

Started during or was directly caused by service

Secondary - caused by a different service connected condition

Aggravation - made worse by a different service connected condition

Rating Increase

Other

Let us know any information that would help us understand your claim (please do not include any confidential or sensitive information):

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Dr. Deborah Miller

Dr. Frank Bevacqua

Whoever has the earliest availability

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Work with
Dr. Miller

Muncie, IN 47305

USA

(765) 273-3734‬

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