Form FL 29-551 FL 29-551 Report of Treatment in Hospital

DEPARTMENT OF VETERANS AFFAIRS

In Reply Refer To:

We are considering a claim for disability insurance benefits for the insured veteran named above. The
veteran appears to have been treated at your facility during the following periods:

OMB Approved No. 2900-0119
Respondent Burden: 12 minutes

ADMISSIONS
FROM

TO

OUTPATIENT TREATMENT
FROM
TO

To help us make a decision on this claim, we need copies of the discharge summaries and outpatient
treatment records for the periods shown above. The insured veteran’s claim authorizes us to request this
information from you.
Please return the copy of this letter with your reply.
Thank you for helping us assist this veteran.
Department of Veterans Affairs
Enclosures
PRIVACY ACT INFORMATION: The VA will not disclose information collected on this form to any source other than what has been
authorized under the Privacy Act of 1974 or Title 5, Code of Federal Regulations 1.526 for routine uses identified in the VA system of records,
36VA00, Veterans and Armed Forces Personnel U.S. Government Life Insurance Records - VA, published in the Federal Register. Your
obligation to respond is voluntary, but your failure to provide us the information could impede processing.
RESPONDENT BURDEN: We need this information to determine your eligibility for VA Insurance benefits (38 U.S.C. 5902). Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average 12 minutes to review the instructions find the
information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed.
You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the
OMB Internet page at www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get
information on where to send comments or suggestions about this form.
FL 29-551
APR 2005 (RS)