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Do You Qualify

Do You Qualifylpd-admin2023-05-18T15:43:23-06:00

Former Worker

You May Qualify for Benefits

Fill out the form below to determine if you qualify for atomic and nuclear worker benefits. Nuclear Care Partners offers benefits guidance to ensure you maximize your benefits. Some services that may be covered to treat approved illnesses under the EEOICPA are in-home care, doctor office visits, and more.

1Name

2Contact Details

3Additional Information

Are you filling this out for yourself or a family member/friend?(Required)

Myself

Family Member/Friend

Are you a former atomic worker?(Required)

Yes

No

Name(Required)

First Last

Your Name(Required)

First Last

Your Phone(Required)

Are they a former atomic worker?(Required)

Yes

No

Former Worker's Name(Required)

First Last

Phone(Required)

Phone Type(Required)

Email

(optional)

Enter Email Confirm Email

Address(Required)

Street Address City State ZIP Code

What facility or site did you work at?(Required)

Approximate dates worked there:(Required)

Where are you in your journey to applying for EEOICPA benefits?(Required)

I’m in the process of applying but could use some guidance

I’ve applied and have received my white medical card

I haven’t done anything, what is the EEOICPA?

I’ve applied and been denied

Have you been diagnosed with cancer or a chronic illness such as COPD, kidney disease, lung disease, or asbestosis that may be linked to your work exposure?(Required)

Yes

No

Do you experience symptoms like shortness of breath that may be linked to an undiagnosed condition?(Required)

(If yes, we can help you find a doctor to get tested for conditions that may qualify you for benefits.)

Yes

No

How did you hear about us?(Required)

Postcard

Atomic Health Newsletter

Social Media (Facebook)

Friend/Family

Digital Ad

Newspaper

Radio

Other

Please Specify:(Required)

Please Specify:(Required)

Name

This field is for validation purposes and should be left unchanged.

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