Form SGLV 8600 SGLV 8600 Servicemembers' Group Life Insurance Traumatic Injury Pr

SERVICEMEMBERS’ GROUP LIFE INSURANCE TRAUMATIC
INJURY PROTECTION PROGRAM (TSGLI)
Administered by the Office of Servicemembers’ Group Life Insurance

Application for TSGLI Benefits
Please submit your completed claim to your branch of service below.
TSGLI Branch of Service Contacts
Branch

Contact Information

Submit Claim by Fax

Submit Claim by E-mail

Submit Claim by Postal Mail

Army
All Components

Phone: (800) 237-1336
Website: www.tsgli.army.mil

(866) 275-0684

[email protected]

Army Human Resources Command
Traumatic SGLI (TSGLI)
200 Stovall Street
Alexandria, VA 22332-0470

Marine Corps
All Components

Phone: (877) 216-0825 or (703) 432-9277
Website: https://www.manpower.usmc.
mil/pls/
portal/url/page/m_ra_home/wwr/
wwr_a_command_element/wwr_d_regimental_staff/3_s3/wwr_tsgli

(888) 858-2315

[email protected]

HQ, Marine Corps
Attn: WWR-TSGLI
3280 Russell Road
Quantico, VA 22134

Navy
All Components

Phone: (800) 368-3202 / 901-874-2501
DSN 882
Website: www.npc.navy.mil/Command
Support/ CasualtyAssistance/TSGLI

(901) 874-2265

[email protected]

Navy Personnel Command
Attn: PERS-62
5720 Integrity Drive
Millington, TN 38055-6200

Air Force
Active Duty

Phone: (800) 433-0048
Website:
ask.afpc.randolph.af.mil

(210) 565-2348

[email protected]

AFPC/DPWC
550 C Street West, Suite 14
Randolph AFB, TX 78150-4716

Air Force
Reserves

Phone: (800) 525-0102

(303) 676-6255

[email protected]

HQ, ARPC/DPPE
6760 E Irvington Place, #4000
Denver, CO 80280-4000

Air
National
Guard

Phone: (703) 607-0901

(703) 607-0033

[email protected]

NCOIC, Customer Operations
Air National Guard Bureau
1411 Jefferson Davis Hwy
Suite 10718
Arlington, VA 22202

Coast Guard

Phone: (202) 475-5391

(202) 475-5927

[email protected]

COMDT (CG-1222)
2100 2nd Street SW
Washington, DC 20593-0001

Public Health
Services

Phone: (301) 594-2963

(301) 594-2973 or
(800) 733-1303

[email protected]

PHS Compensation Branch
Parklawn Building
5600 Fishers Lane, Rm 4-50
Rockville, MD 20857

NOAA
Corps

Phone: (301) 713-3444

(301) 713-4140

[email protected]

U.S. Dept. of Commerce, NOAA
8403 Colesville Rd, Suite 500
Silver Spring, MD 20910

OMB Control Number: 2900-0671
SGLV 8600, October 2008

Respondent Burden: 45 minutes

GL.2005.261 Ed. 9/2008 107640-0908-PDF
SGLV 8600, Oct, 2008, (Supercedes GL 2005.261)
GL.2005.261 10/2008

(Supersedes GL.2005.261 09/2005)

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OMB Control Number: 2900-00671
Respondent Burden: 45 minutes

GENERAL INFORMATION
The Servicemembers’ Group Life Insurance Traumatic Injury Protection (TSGLI) program is a rider to Service member’s Group Life Insurance
(SGLI). The TSGLI rider provides for payment to service members who are severely injured (on or off duty) as the result of a traumatic event and
suffer a loss that qualifies for payment under TSGLI. TSGLI is designed to help traumatically injured service members and their families with
financial burdens associated with recovering from a severe injury. TSGLI payments range from $25,000 to $100,000 based on the qualifying loss
WHO IS ELIGIBLE?
Effective December 1, 2005, all service members who are insured under SGLI and …

n experience a traumatic event

n that results in a traumatic injury

n which is listed as a qualifying loss

are eligible to receive a TSGLI payment. Service members who were severely injured between October 7, 2001 and November 30, 2005 in the
theaters of operation for Operation Enduring Freedom or Operation Iraqi Freedom may also be eligible for TSGLI payment. Members should
contact their branch of service for more information.
What is a Traumatic Event?
A traumatic event is the application of external force, violence, chemical, biological, or radiological weapons, accidental ingestion of a
contaminated substance, or exposure to the elements that causes damage to your body.
What is a Traumatic Injury?
A traumatic injury is the physical damage to your body that results from a traumatic event.
What is a Qualifying Loss?
A qualifying loss is a traumatic injury that is listed on the TSGLI Schedule of Losses, which lists all covered losses and payment amounts. You may
view the complete Schedule of Losses and other TSGLI information at www.insurance.va.gov/sgliSite/TSGLI.htm Your branch of service TSGLI
office will determine whether your injury is a qualifying loss for TSGLI purposes.
HOW TO FILE A TSGLI CLAIM
Filing a TSGLI claim is a three-step process in which the service member [or guardian or power of attorney or military trustee] and a medical
professional must complete and submit the appropriate parts of the TSGLI Claim Form as follows:
Step 1

Step 2

Step 3

The service member [or guardian or power of
attorney or military trustee]…

The medical professional…

The medical professional OR the service member [or
guardian or power of attorney or military trustee]…

must complete Part A (pages 3 through 6) of the
form and give it to a medical professional to
complete Part B. Note: If a guardian or power
of attorney completes Part A, they must include
copies of letters of guardianship, letters of
conservatorship, power of attorney, or durable
power of attorney (if appropriate).

must complete Part B (pages 7 through 12).

must forward Parts A & B to the member’s branch
of service TSGLI office listed on the front cover of
this form.

SGLV 8600, October 2008

GL.2005.261 Ed. 9/2008
SGLV 8600, Oct, 2008, (Supercedes GL 2005.261)
GL.2005.261 10/2008

(Supersedes GL.2005.261 09/2005)

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COMPLETING THE FORM
Instructions on completing the TSGLI Claim Form are included in each section. When completing the form, the service member guardian, power
of attorney or military trustee must complete the service member’s Social Security number on each page of the form. If you have questions about
completing the form or if the member is deceased, please contact the branch of service TSGLI office listed on the front cover of this form.
Claim decision and payment
Who Makes the Decision on My Claim?
Your branch of service TSGLI office will make the decision on your claim based upon the information in Parts A and B of the TSGLI Claim Form.
They will then forward their decision to the Office of Servicemembers’ Group Life Insurance (OSGLI) for appropriate action.
Who Will Receive the TSGLI Payment?
Payment will be made directly to the member. If the member is incompetent, payment will be made under the appropriate letters of guardianship/
conservatorship or a power of attorney to the guardian or power of attorney on the member’s behalf. If the member dies after qualifying for
payment, the payment will be made to the member’s current listed SGLI beneficiary(ies). The member must survive for seven days (168 hours) from
the date of the traumatic event to be eligible for TSGLI.
How the TSGLI Payment Will be Made?
If your branch of service TSGLI office approves your claim, OSGLI will make the TSGLI benefit payment. There are three payment methods used
for TSGLI benefits: Prudential’s Alliance Account®*, Electronic Funds Transfer (EFT), or check.

1. P
 rudential’s Alliance Account®* — (for member only) An interest-bearing account will be established in the name of the member.
The member can access the money immediately using the draft book (“checkbook”). There are no monthly service fees or per-check
charges and additional checks can be ordered at no additional cost. If you have any questions about Alliance, please call Alliance
Customer Service toll free at 877-255-4262 or the OSGLI Claim Department toll free at 800-419-1473.

2. E lectronic Funds Transfer (EFT) — Your bank account will be electronically credited with the TSGLI payment amount. Depending on
your bank, payments will be credited three to five days from the date the payment is authorized.

 ote: If the member does not choose EFT and there is no guardian or power of attorney, the payment will be made through
N
Prudential’s Alliance Account.
3. C
 heck Payment — (for guardian or power of attorney only) A check will be issued to the guardian or power of attorney or military
trustee on behalf of the member.

RESPONDENT BURDEN: We need this information to allow service members who are insured under Servicemembers Group Life Insurance and
suffer a loss from a traumatic injury to receive monetary compensation. Title 38, United States Code, allows us to ask for this information. We
estimate that you will need an average of 45 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.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this survey.
PRIVACY ACT NOTICE: VA will not disclose information collected on this survey to any source other than what has been authorized under the
Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses identified in the VA system of records , 36VA00, Veterans
and Armed Forces Personnel U.S. Government Life Insurance Records-VA, and published in the Federal Register. Your obligation to respond
is voluntary. Giving us your Social Security number account information is mandatory. Applicants are required to provide their Social Security
number under Title 38 USC
1980A. VA will not deny an individual benefits for refusing to provide his or her Social Security number unless the disclosure is required by a
Federal Statute of law in effect prior to January 1, 1975, and still in effect.

* Open Solutions BIS, Inc. is the Administrator of the Prudential Alliance Account Settlement Option, a contractual obligation of The Prudential
Insurance Company of America, located at 751 Broad Street, Newark, NJ 07102-3777. Check clearing is provided by JPMorgan Chase Bank,
N.A. and processing support is provided by Integrated Payment Systems, Inc. Alliance Account balances are not insured by the Federal Deposit
Insurance Corporation (FDIC). Open Solutions BIS, Inc., JPMorgan Chase Bank, N.A., and Integrated Payment Systems, Inc. are not Prudential
Financial companies.
SGLV
8600, October
2008
GL.2005.261
Ed. 9/2008

SGLV 8600, Oct, 2008, (Supercedes GL 2005.261)

(Supersedes GL.2005.261 09/2005)

GL.2005.261 10/2008

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PART A - Member’s Claim Information and Authorization - to be completed by the member, guardian, power of attorney or military trustee
Service member’s Social Security Number

1 Service member
Information

Service member’s First Name

MI

The service member,
guardian or power of Date of Birth (mm dd yyyy)
attorney MUST fill
in member’s Social
Security number at the
Branch of Service
top of pages 3 through
Army
PHS
13 of this form.
Navy
Air Force

Gender
Male
Female
Marines
NOAA

Service member’s Last Name

Marital Status
Married

Active Duty
National Guard

Address of Record (number and street)
Important Note:
Contact information
must be completed.
Incomplete information City
will delay payment of
your claim.

Reserves
Coast Guard

Divorced

Widowed

Rank/Grade

Apt. (if any

State

Single

Telephone Number

ZIP Code

E-mail Address

Unit (at time of injury)

2 Guardian,
Power of
Attorney or
Military Trustee
Information

Complete this section ONLY if a guardian, power of attorney or military trustee will receive payment on behalf of the member.
First Name

MI

Injury
Information

Mailing Address (number and street)

Important Note:
Please include
copies of the letters
City
of guardianship,
conservatorship, or
Power of Attorney, etc.
Telephone Number
with this form.
Failure to include this
documentation will
delay payment of the
claim.

3 Traumatic

Last Name

Apartment (if any)

State

ZIP Code

Fax Number

Injuries that Qualify for TSGLI Payment
In order to qualify for the TSGLI benefit, you must have experienced a traumatic event that resulted in a traumatic injury
that is listed as a qualifying loss on the TSGLI Schedule of Losses.
Definitions:
Traumatic Event — A traumatic event is the application of external force, violence, chemical, biological, or radiological
weapons, accidental ingestion of a contaminated substance, or exposure to the elements that causes damage to your body.
Traumatic Injury — A traumatic injury is the physical damage to your body that resulted from a traumatic event (illness or
disease is not covered).
Qualifying Loss — A qualifying loss is a traumatic injury that is listed on the TSGLI Schedule of Losses. You may view the
complete Schedule of Losses at www.insurance.va.gov/sgliSite/TSGLI.htm.

SGLV
8600, October
2008
GL.2005.261
Ed. 9/2008

SGLV 8600, Oct, 2008, (Supercedes GL 2005.261)

(Supersedes GL.2005.261 09/2005)

GL.2005.261 10/2008

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PART A - Member’s Claim Information and Authorization (cont’d) - to be completed by the member, guardian, power of attorney or military trustee
Service member’s Social Security Number

3 Traumatic
Injury
Information

Information About Your Loss
Is the loss you are claiming the result of any of the following:

a. an intentionally self-inflicted injury or an attempt to inflict such injury?

Yes

No

b. use of an illegal or controlled substance that was not administered
or consumed on the advice of a medical doctor?

Yes

No

c. the medical or surgical treatment of an illness or disease?

Yes

No

d. a traumatic injury sustained while committing or attempting to commit a felony?

Yes

No

e. a physical or mental illness or disease (not including illness or disease caused
by a wound infection, a chemical, biological, or radiological weapon, or the accidental
ingestion of a contaminated substance)?

Yes

No

If you answered yes…
to any of the questions above, you are not eligible for TSGLI payment and should not file a claim.
If you are not sure…
whether your loss is a result of one of the items above, please contact your Branch of Service TSGLI Office to find out if you
are eligible.
Tell us about your traumatic Injury
In the box below, please describe your injury and give the date, time and location where it occurred.
Traumatic Injury Information

SGLV
8600, October
2008
GL.2005.261
Ed. 9/2008

SGLV 8600, Oct, 2008, (Supercedes GL 2005.261)

(Supersedes GL.2005.261 09/2005)

GL.2005.261 10/2008

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PART A - Member’s Claim Information and Authorization (cont’d) - to be completed by the member, guardian, power of attorney or military trustee
Service member’s Social Security Number

41

Payment
Options
Please choose one
of the three payment
options by checking
the appropriate
box and filling
in the requested
information.
Payment Option 1
– Prudential’s
Alliance Account
An interest-bearing
account will be
established in the
name of the member,
who can access the
money using the draft
book (“checkbook”).
Payment Option 2
– Electronic
Funds Transfer
Payment will be
made to the bank
account indicated.
This option can be
selected by member
or, if applicable, the
guardian or power of
attorney.

Please choose one of the three payment options below:

Payment Option 1 - Prudential’s Alliance Account® (for member ONLY) To have the payment made through
Prudential’s Alliance Account, fill in the mailing address below (street address only, no PO boxes.)
Service member’s Mailing Address for Payment - No P.O. Boxes

Apartment, Ward or Room (if any)

City

State

ZIP Code

Payment Option 2 - Electronic Funds Transfer (EFT) To have the payment made by EFT, fill in your banking information
below. A sample check is provided to help you locate the bank routing and bank account numbers. Please print clearly.
Bank Routing Number

Bank Account Number

Checking
Savings

Bank Name

First Name

MI

Bank Phone Number

Last Name

Customer’s Name
Street Address
City, State, Zip

The bank routing
number is always
9 digits and
appears between
the symbols

Check
Sample

Check No. 1234

PAY TO THE
ORDER OF________________________________________________ $
________________________________________________________

Dollars

Bank Name
Street Address
City, State, Zip
223207349

Bank Routing Number

00123012201234

The bank account
number varies in
length and may
contain dashes or
spaces. The
symbol indicates
the end of the
account number.

1234

Check Number (not needed)

Bank Account Number

Payment Option 3 –
Payment Option 3 - Check (for guardian, power of attorney or military trustee ONLY)
Check
To have the payment made by check, fill in the guardian or power of attorney mailing address below.
A check will be issued
to the guardian or
Mailing Address for Payment - No P.O. Boxes
Apartment (if any)
power of attorney on
behalf of the service

member.
City
State
ZIP Code

Signature

Member, guardian,
or power of attorney
must sign here.
Description of Authority:
If the guardian, power
of attorney or military
trustee completes this
section, they must also
indicate their authority
to act on behalf of the
member (e.g. guardian,
conservator, etc.)

SGLV
8600, October
2008
GL.2005.261
Ed. 9/2008

Third Party
Authorization

(Optional) I authorize the following person to speak with OSGLI or the Branch of Service about my
claim (this can be a spouse, parent, friend or another person who is helping you with your claim).

First Name

GL.2005.261 10/2008

Last Name

X
Signature of service member, guardian, or power of attorney

Date (mm dd yyyy)

WARNING: Any intentional false statement in this claim or willful misrepresentation relative thereto is subject to
punishment by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001)

SGLV 8600, Oct, 2008, (Supercedes GL 2005.261)

(Supersedes GL.2005.261 09/2005)

MI

Description of Authority to
act on behalf of the member
(Guardian, POA, etc.)

Member must complete and sign the HIPPA release on next page

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PART A - Member’s Claim Information and Authorization (cont’d) - to be completed by the member, guardian, power of attorney or military trustee
Service member’s Social Security Number

16

Member must complete and sign the HIPAA release, below:
Authorization
for Release of
Information
I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, medical
to Branch
examiner or other health care provider that has provided treatment, payment or services pertaining to:
of Service
First Name
MI
Last Name
and Office of
Servicemembers’

Group Life
Date of Birth (mm dd yyyy)
Insurance
The member,
guardian, power
of attorney, or
military trustee
must complete and
sign this section.
Failure to
complete this
section will
delay payment
of claim

or on my behalf (“My Providers”) to disclose my entire medical record for me or my dependents and any other health information
concerning me to the Branch of Service and Office of Servicemembers’ Group Life Insurance (OSGLI) and its agents, employees,
and representatives. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol,
drugs, and tobacco, but excludes psychotherapy notes. OSGLI, an administrative unit created by Prudential to administer the
Servicemembers’ Group Life Insurance Program and OSGLI administers the TSGLI program on behalf of the Department of Veterans
Affairs.
I authorize all non-health organizations, any insurance company, employer, or other person or institutions to provide any
information, data or records relating to credit, financial, earnings, travel, activities or employment history to OSGLI.
Unless limits* are shown below, this form pertains to all of the records listed above.

This authorization By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to
this authorization and I instruct My Providers to release and disclose my entire medical record without restriction.
is intended to
comply with the
This information is to be disclosed under this Authorization so that my Branch of Service and OSGLI may: 1) administer claims
HIPAA Privacy Rule. and determine or fulfill responsibility for coverage and provision of benefits, 2) administer coverage; and 3) conduct other legally
permissible activities that relate to any coverage I have applied for with OSGLI.
This authorization shall remain in force for 24 months following the date of my signature below, while the coverage is in force,
except to the extent that state law imposes a shorter duration. A copy of this authorization is as valid as the original. I understand
that I have the right to revoke this authorization in writing, at any time, by sending a written request for revocation to OSGLI at: 80
Livingston Avenue, Roseland, NJ 07068. I understand that a revocation is not effective to the extent that any of My Providers has
relied on this Authorization or to the extent that OSGLI has a legal right to contest a claim under an insurance policy or to contest
the policy itself. I understand that any information that is disclosed pursuant to this authorization may be redisclosed and no longer
covered by federal rules governing privacy and confidentiality of health information.
I understand that if I refuse to sign this authorization to release my complete medical record, OSGLI may not be able to process my
claim for benefits and may not be able to make any benefit payments. I understand that I have the right to request and receive a
copy of this authorization.
*Limits, if any:
NOTE: This release authorizes the branch of service and OSGLI to look at medical records. You may also be asked to provide these
documents.

Signature
X
The member,
Signature of service member, guardian, power of attorney or military trustee
guardian, power of Date (mm dd yyyy)
attorney or military
trustee must sign
here.
SGLV
8600, October
2008
GL.2005.261
Ed. 9/2008

SGLV 8600, Oct, 2008, (Supercedes GL 2005.261)

(Supersedes GL.2005.261 09/2005)

GL.2005.261 10/2008

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Description of Authority to
act on behalf of the member
(Guardian, POA, etc.)

Page 6

Service member’s Social Security Number

PART B - Medical Professional’s Statement - to be completed by a medical professional who is a licensed practitioner of the healing arts
acting within the scope of his/her practice.
1

Patient
Information

Patient’s First Name

MI

Patient’s Last Name

Date of Injury (mm dd yyyy)

Is the patient capable of handling his/her own affairs?

Yes

No

If patient is deceased, please provide:
Date of Death (mm dd yyyy)

Time of Death
A.M.
P. M.

:
Cause of Death

2

Hospitalization
Information
Please complete
this section for
ALL patients.

Reason for Hospitalization – Please give the predominant reason the patient was hospitalized
Traumatic Brain Injury

Other Traumatic Injury

Longest Period of Hospitalization – Please give the beginning and ending dates for the longest period of consecutive days the patient was
hospitalized. The count of consecutive hospitalization days begins when the injured member is transported to the hospital (if applicable), includes
the day of admission, continues through subsequent transfers from one hospital to another, and includes the day of discharge.
Date transported

Date of admittance to first hospital

Date of discharge from last hospital

OR Check here
if still
hospitalized

Name and location of hospital (if more than one hospital, list all)

Definition of a hospital – A hospital that is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on
Accreditation of Healthcare Organizations. This includes Combat Support Hospitals, Air Force Theater Hospitals and Navy Hospital Ships.
Hospital does not include a nursing home. Neither does it include an institution, or part of one, which: (1) is used mainly as a place for
convalescence, rest, nursing care or for the aged; or (2) furnishes mainly homelike or Custodial Care, or training in the routines of daily living;
or (3) is for residential or domiciliary living; or (4) is mainly a school

3

Qualifying
Losses Suffered
by Patient
Instructions:
Please check the
box next to each
loss the patient has
experienced and fill
in any additional
information
requested. Omitted
information, such
as sight or hearing
measurements, will
delay payment of
the claim.

Hospitalization of at least 15 consecutive
days as defined above.

Hospitalization
Hospitalization for at least 15 consecutive days
Loss of Sight
Loss of sight in left eye or
anatomical loss of left eye

Date of onset/loss

Loss of Sight is defined as:
n

Loss of sight in right eye or
anatomical loss of right eye

n

Visual Acuity and Field

Left Eye

Right Eye
n

Best corrected visual acuity

Loss of Speech
Loss of speech

SGLV 8600, Oct, 2008, (Supercedes GL 2005.261)

(Supersedes GL.2005.261 09/2005)

GL.2005.261 10/2008

Visual acuity in at least one eye of greater (better)
than 20/200 with corrective lenses and a visual
field of 20 degrees or less OR,
Anatomical loss of eye. Loss of sight must be expected to
b e permanent OR must have lasted at least 120 days

Visual Field (degrees)
Date of onset

Loss of Speech is defined as:
Organic loss of speech (lost the ability to express oneself,
both by voice and whisper, through normal organs for speech),
even if member uses an artificial appliance, such as a voice
box, to simulate speech. Loss of speech must be clinically
stable and unlikely to improve.

Patient’s loss MUST
meet the definition
of loss given.
SGLV
8600, October
2008
GL.2005.261
Ed. 9/2008

Visual acuity in at least one eye of 20/200 or
less (worse) with corrective lenses OR,

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Service member’s Social Security Number

PART B - Medical Professional’s Statement (con’t) to be completed by a medical professional who is a licensed practitioner of the healing
arts acting within the scope of his/her practice.
35

Qualifying
Losses
Suffered by
Patient (cont’d)

Loss of Hearing

Loss of hearing is defined as:

Date of onset

Average hearing threshold sensitivity for air conduction of
at least 80 decibels. Hearing Acuity must be measured at
500 Hz, 1000 Hz and 2000 Hz to calculate the average hearing threshold. Loss of hearing must be clinically stable and
unlikely to improve.

Loss of hearing in left ear
Loss of hearing in right ear
Hearing Activity
Average Hearing Acuity (measured
without amplification device)

Left Ear

Right Ear

db

db
Burns are defined as:

Burns

2nd degree (partial thickness) or worse burns over 20% of the
body including the face and head OR 20% of the face only.

2nd degree or worse burns to the body including face and head
2nd degree or worse burns to the face only
Percentage of
body affected

Percentage of
face affected

%

Note: Percentage may be measured using
the Rule of Nines or any other acceptable alternative

%

Coma is defined as:

Coma

Coma with brain injury measured at a Glasgow Coma Score
of 8 or less that lasts for 15, 30, 60 or 90 consecutive days.

Coma
Date of onset

OR

Date of recovery

C heck here if coma is ongoing

 Glasgow score at 15 days

Important:

Number of days includes the date the coma began and the
date the member recovered from the coma.

 Glasgow score at 30 days

 Glasgow score at 60 days

Facial Reconstruction

Facial
Reconstruction:
If the patient is
undergoing facial
reconstruction, a
surgeon MUST
certify this section
by checking the box,
printing his/her name
and signing on the
appropriate line.

 Glasgow score at 90 days

Facial Reconstruction is defined as:

Upper or lower jaw

50% of left zygomatic

50% of cartilaginous nose

50% of right zygomatic

50% of upper lip

50% of left mandibular

Reconstructive surgery to correct traumatic avulsions of the
face or jaw that cause discontinuity defects, specifically
surgery to correct discontinuity loss of the following:
n

upper or lower jaw

n

50% or more of the cartilaginous nose

50% of lower lip

50% of right mandibular

n

50% or more of the upper or lower lip

30% of left periorbita

50% of left infraorbita

n

30% or more of the periorbita

30% of right periorbita

50% of right infraorbita

n

50% of left temple

50% of chin

50% of right temple

50% of forehead

t issue in 50% or more of any of the following facial
subunits: forehead, temple, zygomatic, mandibular,
infraorbital or chin.

Certification of Surgeon
Date of first surgery

Name of Surgeon

X
Signature of Surgeon
Date (mm dd yyyy)

SGLV
8600, October
2008
GL.2005.261
Ed. 9/2008

SGLV
8600, Oct, 2008, (Supercedes GL 2005.261)

(Supersedes GL.2005.261 09/2005)

GL.2005.261 10/2008

*8732609*

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Page 8

Service member’s Social Security Number

PART B - Medical Professional’s Statement (con’t) to be completed by a medical professional who is a licensed practitioner of the healing
arts acting within the scope of his/her practice.
35

Qualifying
Losses
Suffered by
Patient (cont’d)

Amputation is: is the severance or removal of a limb or part of a limb, including both severance due to a traumatic injury, or surgical removal
that is required for the treatment of a traumatic injury.
Amputation of Hand

Date of amputation

Amputation of Hand is defined as:
Amputation of hand at or above* the wrist

Amputation of left hand

*at or above: closer to the body
Amputation of right hand
Amputation of Fingers

Date of amputation

Amputation of Fingers is defined as:

Amputation of 4 fingers/
left hand

n

Amputation of 4 fingers/
right hand

n

Amputation of left thumb

A
 mputation of four fingers on the same hand
(not including the thumb) at or above* the
metacarpophalangeal joint OR,
A
 mputation of thumb at or above the
metacarpophalangeal joint.

*at or above: closer to the body

Amputation of right thumb
Amputation of Foot

Date of amputation

Amputation of Foot is defined as:

Amputation of left foot

n
n

Amputation of right foot

A
 mputation of foot at or above the ankle OR,
A
 mputation of all toes (including the big toe) on the same
foot at or above the metatarsophalangeal joint.

*at or above: closer to the body

Amputation of Toes

Date of amputation

Amputation of Toes is defined as:

Amputation of 4 toes/
left foot

n

A
 mputation of four toes on one foot at or above the
metatarsophalangeal joint (not including the big toe)

OR,

Amputation of 4 toes/
right foot

n

Amputation of big toe/
left foot

A
 mputation of big toe at or above the metatarsophalangeal joint.

*at or above: closer to the body

Amputation of big toe/
right foot

Important:
Limb Salvage:
If the patient is
undergoing limb
salvage, a surgeon
MUST certify this
section by checking
the box, printing his/
her name and
signing on the
appropriate line.

Limb Salvage

Limb Salvage is defined as:

Date of first surgery

A series of operations designed to save an arm or leg rather
than amputate.

Salvage of left arm

A surgeon must certify that:

Salvage of left leg

n

Salvage of right arm
n

Salvage of right leg
Certification of Surgeon
The option of amputation was offered to the patient and the patient has
chosen to pursue limb salvage.

T he option of amputation of limb(s) was offered to
the patient as a medically justified alternative to limb
salvage and
T he patient has chosen to pursue limb salvage.

Additional Comments

Name of Surgeon

X
Signature of Surgeon
Date (mm dd yyyy)

SGLV
8600, October
2008
GL.2005.261
Ed. 9/2008

SGLV
8600, Oct, 2008, (Supercedes GL 2005.261)

(Supersedes GL.2005.261 09/2005)

GL.2005.261 10/2008

*8732610*

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Service member’s Social Security Number

PART B - Medical Professional’s Statement (con’t) to be completed by a medical professional who is a licensed practitioner of the healing
arts acting within the scope of his/her practice.
35

Qualifying
Losses
Suffered by
Patient (cont’d)
Description
of Injury/
Assistance Needed
Please provide a
description of the
injury and
descriptions of the
assistance needed to
perform each ADL.
Failure to provide this
information may delay
payment of claim.

Paralysis

Paralysis is defined as:

Date of onset

Complete paralysis due to damage to the spinal cord or
associated nerves, or to the brain. A limb is defined as an
arm or a leg with all its parts. Paralysis must fall into one
of the four categories listed below:

Quadriplegia
Paraplegia
Hemiplegia

n

Q
 uadriplegia - paralysis of all four limbs

n

P araplegia - paralysis of both lower limbs

n

Uniplegia

n

H
 emiplegia - paralysis of the upper and lower limbs on
one side of the body
U
 niplegia- paralysis of one limb

Inability to Independently Perform Activities of Daily Living (ADL)
Inability to Independently Perform ADL is defined as:
Inability to independently perform at least two of six ADL (bathing, continence, dressing, eating, toileting and transferring). Inability must last
for at least 15 consecutive days for traumatic brain injury and at least 30 consecutive days for any other traumatic injury.
The patient is considered unable to perform an activity independently only if he or she REQUIRES assistance to perform the activity. If the
patient is able to perform the activity by using accommodating equipment, such as a cane, walker, commode, etc., the patient is considered
able to independently perform the activity without requiring assistance.
Requires Assistance is defined as:
n

p hysical assistance (hands-on),

n

s tand-by assistance (within arm’s reach),

v erbal assistance (must be instructed because of cognitive impairment),
without which the patient would be INCAPABLE of performing the task.
n

What is the
predominant reason What is the predominant reason the patient is/was unable to independently perform ADL?
the patient is/was
Traumatic Brain Injury
Other Traumatic Injury
unable to
(Please
describe
injury
and
give
reason(s)
it resulted in inability to perform activities of daily living.)
independently
perform ADL?
Check the
predominant reason
the patient cannot
independently
perform ADL and
describe the injury in
Patient is UNABLE to bathe independently if…
Unable to bathe independently
the box provided.
Start date
End date
He/she requires assistance from another person to bathe
Which ADL is the
(including sponge bath) more than one part of the body or get
patient unable to
in or out of the tub or shower.
perform?
Describe assistance needed:
OR
C heck here if inability is ongoing
Check each ADL
the patient cannot
Type of assistance required (check all that apply)
perform;
physical assistance (hands-on)
verbal assistance (must be
AND;
instructed because of
Fill in the dates
stand-by assistance
cognitive impairment)
inability began and
(within arm’s reach)
ended or indicate
inability is ongoing
Patient is UNABLE to maintain continence
Unable to maintain continence independently
independently if…
Start date
End date

OR

He/she is partially or totally unable to control bowel and
bladder function or requires assistance from another person to
manage catheter or colostomy bag.

C heck here if inability is ongoing

Describe assistance needed:

Type of assistance required (check all that apply)
physical assistance (hands-on)

verbal assistance (must be
instructed because of
cognitive impairment)

stand-by assistance
(within arm’s reach)

SGLV
8600, October
2008
GL.2005.261
Ed. 9/2008

SGLV 8600, Oct, 2008, (Supercedes GL 2005.261)

(Supersedes GL.2005.261 09/2005)

GL.2005.261 10/2008

*87326011*

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Service member’s Social Security Number

PART B - Medical Professional’s Statement (con’t) to be completed by a medical professional who is a licensed practitioner of the healing
arts acting within the scope of his/her practice.
35

Qualifying
Losses
Suffered by
Patient (cont’d)

Inability to Independently Perform Activities of Daily Living (ADL) (cont’d)
Patient is UNABLE to dress independently if…

Unable to dress independently
Start date

End date

He/she requires assistance from another person to get and
put on clothing, socks or shoes.
Describe assistance needed:

Require
Assistance
is defined as:
np
 hysical
assistance
(hands-on),
ns
 tand-by
assistance (within
arm’s reach),
nv
 erbal assistance
(must be
instructed
because of
cognitive
impairment),
without which
the patient would
be INCAPABLE
of performing the
task.

OR

C heck here if inability is ongoing

Type of assistance required (check all that apply)
physical assistance (hands-on)

verbal assistance (must be
instructed because of
cognitive impairment)

stand-by assistance
(within arm’s reach)

Patient is UNABLE to eat independently if…

Unable to eat independently
Start date

OR

End date

He/she requires assistance from another person to:

C heck here if inability is ongoing

t ake liquid nourishment from a straw or cup OR,

Describe assistance needed:

verbal assistance (must be
instructed because of
cognitive impairment)

stand-by assistance
(within arm’s reach)

Patient is UNABLE to toilet independently if…

Unable to toilet independently
Start date

OR

g et food from plate to mouth OR,

n

he/she is fed intravenously or by a feeding tube

Type of assistance required (check all that apply)
physical assistance (hands-on)

n

End date

He/she must use a bedpan or urinal to toilet OR,
he/she requires assistance from another person with any of
the following: going to and from the toilet, getting on and off
the toilet, cleaning self after toileting, getting clothing off
and on.

C heck here if inability is ongoing

Describe assistance needed:

Type of assistance required (check all that apply)
physical assistance (hands-on)

verbal assistance (must be
instructed because of
cognitive impairment)

stand-by assistance
(within arm’s reach)

Patient is UNABLE to transfer independently if…

Unable to transfer independently
Start date
End date

He/she requires assistance from another person to move into
or out of a bed or chair.
Describe assistance needed:

OR

C heck here if inability is ongoing

Type of assistance required (check all that apply)
physical assistance (hands-on)

verbal assistance (must be
instructed because of
cognitive impairment)

stand-by assistance
(within arm’s reach)

SGLV
8600, October
2008
GL.2005.261
Ed. 9/2008

SGLV 8600, Oct, 2008, (Supercedes GL 2005.261)

(Supersedes GL.2005.261 09/2005)

GL.2005.261 10/2008

*87326012*

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Service member’s Social Security Number

PART B - Medical Professional’s Statement (con’t) to be completed by a medical professional who is a licensed practitioner of the healing
arts acting within the scope of his/her practice.
45

Other
Information

To your knowledge, were any of the losses indicated in Part B due to:
a. an intentionally self-inflicted injury or an attempt to inflict such injury,
b. use of an illegal or controlled substance that was not administered or consumed on the advice of a medical doctor,
c. the medical or surgical treatment of an illness or disease,
d. a physical or mental illness or disease (not including illness or disease caused by a pyogenic infection, a chemical, biological, or radiological
weapon, or the accidental ingestion of a contaminated
If yes, please explain below:

5

Medical
Professional’s
Comments

Use this block to provide any additional information about the patient’s injuries. When a narrative description is required, please be
complete and concise.

65

Medical
Professional’s
Information

Name of Medical Professional
First Name

MI

Medical Professional’s Address (number and street)

Last Name

Suite

City

State

Telephone Number

ZIP Code

Fax Number

E-mail Address

Specialty

7

Medical
Professional’s
Signature

Medical Degree

I have observed the patient’s loss.

I have not observed the patient’s loss, but I have reviewed the patient’s medical records.

This Medical Professional’s Statement is based upon my examination of the patient, and/or, a review of pertinent medical
evidence. I understand the patient and/or I may be asked to provide supporting documentation to validate eligibility under the law.
Date (mm dd yyyy)

X

Signature

WARNING: Any intentional false statement in this claim or willful misrepresentation relative thereto is subject to punishment by
a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001)
SGLV
8600, October
2008
GL.2005.261
Ed. 9/2008

SGLV
8600, Oct, 2008, (Supercedes GL 2005.261)

(Supersedes GL.2005.261 09/2005)

GL.2005.261 10/2008

*87326013*

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