VA Form 21-0960L-1 Respiratory Conditions (Other than Tuberculosis and Slee

OMB Approved No. 2900-0781
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/XXXX

RESPIRATORY CONDITIONS (OTHER THAN TUBERCULOSIS AND SLEEP APNEA)
DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE
PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION
BEFORE COMPLETING THIS FORM.
NAME OF PATIENT/VETERAN (First, Middle Initial, Last)

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you
provide on this questionnaire as part of their evaluation in processing the veteran's claim. VA reserves the right to confirm the authenticity of ALL DBQs completed by
private health care providers.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A RESPIRATORY CONDITION? (This is the condition the veteran is

claiming or for which an exam has been requested.)
YES

NO

(If "Yes," complete Item 1B)

NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. If there is no diagnosis, if the diagnosis is different
from a previous diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in the "Remarks"
section. Date of diagnosis can be the date of the evaluation if the clinician is making the initial diagnosis, or an appropriate date determined through record review or
reported history.
1B. SELECT THE VETERAN'S CONDITION (Check all that apply):
ASTHMA

ICD code:

Date of diagnosis:

EMPHYSEMA

ICD code:

Date of diagnosis:

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

ICD code:

Date of diagnosis:

CHRONIC BRONCHITIS

ICD code:

Date of diagnosis:

CONSTRICTIVE BRONCHIOLITIS

ICD code:

Date of diagnosis:

ICD code:

Date of diagnosis:

INTERSTITIAL LUNG DISEASE (If checked, specify):

NOTE - Interstitial lung diseases include but are not limited to asbestosis, diffuse interstitial fibrosis, interstitial pneumonitis, fibrosing alveolitis, desquamative
interstitial pneumonitis, pulmonary alveolar proteinosis, eosinophilic granuloma of lung, drug-induced pulmonary pneumonitis and fibrosis, radiation-induced
pulmonary pneumonitis and fibrosis, hypersensitivity pneumonitis (extrinsic allergic alveolitis) and pneumoconiosis such as silicosis, anthracosis, etc.)
RESTRICTIVE LUNG DISEASE (If checked, specify):
ICD code:

Date of diagnosis:

NOTE - Restrictive lung diseases include but are not limited to diaphragm paralysis or paresis, spinal cord injury with respiratory insufficiency, kyphoscoliosis,
pectus excavatum, pectus carinatum, traumatic chest wall defect, pneumothorax, hernia, etc., post-surgical residual (lobectomy, pneumonectomy, etc.), chronic
pleural effusion or fibrosis.
SARCOIDOSIS

ICD code:

Date of diagnosis:

ICD code:

Date of diagnosis:

ICD code:

Date of diagnosis:

ICD code:

Date of diagnosis:

BENIGN OR MALIGNANT NEOPLASM OR METASTASES OF
RESPIRATORY SYSTEM (If checked, specify):
PULMONARY VASCULAR DISEASE (Including pulmonary

thromboembolism) (If checked, specify):

OTHER DIAGNOSIS (If checked, specify):

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO RESPIRATORY CONDITIONS, LIST USING ABOVE FORMAT:

NOTE - If diagnosed with Sleep Apnea complete VA Form 21-0960L-2, Sleep Apnea Disability Benefits Questionnaire. If diagnosed with Narcolepsy complete VA
Form 21-0960C-6, Narcolepsy Disability Benefits Questionnaire.
VA FORM
XXX XXXX

21-0960L-1

SUPERSEDES VA FORM 21-0960L-1, SEP 2016,
WHICH WILL NOT BE USED.

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PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

SECTION II - MEDICAL RECORD REVIEW
2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT:
C-FILE (VA ONLY)
OTHER, DESCRIBE:

SECTION III - MEDICAL HISTORY

3A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S RESPIRATORY CONDITION (brief summary):

3B. DOES THE VETERAN'S RESPIRATORY CONDITION REQUIRE THE USE OF ORAL OR PARENTERAL CORTICOSTEROID MEDICATIONS?
YES

NO

(If "Yes," complete the following):

Requires chronic low dose (maintenance) corticosteroids
Requires intermittent courses or bursts of systemic (oral or parenteral) corticosteroids
(If checked, indicate number of courses or bursts in past 12 months):
0

1

2

3

4 or more

Requires systemic (oral or parenteral) high dose (therapeutic) corticosteroids for control
Requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications
Other, describe:

(If the veteran has more than one respiratory condition, indicate the condition which is predominantly responsible for the need for corticosteroids or immunosuppressive medications):
3C. DOES THE VETERAN'S RESPIRATORY CONDITION REQUIRE THE USE OF INHALED MEDICATIONS?
YES

NO

(If, "Yes," check all that apply):

Inhalational bronchodilator therapy

(If "Yes," indicate frequency):

Intermittent

Daily

Inhalational anti-inflammatory medication

(If "Yes," indicate frequency):

Intermittent

Daily

Other inhaled medications, describe:

(If the veteran has more than one respiratory condition, indicate the condition which is predominantly responsible for the need for inhaled medications):

3D. DOES THE VETERAN'S RESPIRATORY CONDITION REQUIRE THE USE OF ORAL BRONCHODILATORS?
YES

NO

(If "Yes," indicate frequency):

Intermittent

Daily

3E. DOES THE VETERAN'S RESPIRATORY CONDITION REQUIRE THE USE OF ANTIBIOTICS?
YES

NO

(If "Yes," list antibiotics, dose, frequency and condition for which antibiotics are prescribed):
3F. DOES THE VETERAN REQUIRE OUTPATIENT OXYGEN THERAPY FOR HIS OR HER RESPIRATORY CONDITION?
YES

NO

(If "Yes," does the veteran require continuous oxygen therapy (>17 hours/day?):
YES

NO

(If the veteran has more than one respiratory condition, indicate the condition which is predominantly responsible for the requirement for oxygen therapy):
SECTION IV - PULMONARY CONDITIONS
4. DOES THE VETERAN HAVE ANY OF THE FOLLOWING PULMONARY CONDITIONS?
YES

NO

(If "No," proceed to Section V) (If "Yes," check all that apply):

Asthma
Bronchiectasis
Sarcoidosis
Pulmonary embolism and related diseases
Bacterial lung infection
Mycotic lung infection
Pneumothorax
Gunshot/fragment wound
Cardiopulmonary complications
Respiratory failure
Tumors or neoplasms

(If checked, complete Part A below)
(If checked, complete Part B below)
(If checked, complete Part C below)
(If checked, complete Part D below)
(If checked, complete Part E below)
(If checked, complete Part F below)
(If checked, complete Part G below)
(If checked, complete Part H below)
(If checked, complete Part I below)
(If checked, complete Part J below)
(If checked, complete Part K below)

Other pulmonary conditions, pertinent physical findings or scars due to pulmonary conditions:

(If checked, complete Part I below)
VA FORM 21-0960L-1, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

SECTION IV - PULMONARY CONDITIONS (Continued)
PART A - ASTHMA
1. HAS THE VETERAN HAD ANY ASTHMA ATTACKS WITH EPISODES OF RESPIRATORY FAILURE IN THE PAST 12 MONTHS?
YES

NO
0

(If "Yes," indicate average number of asthma attacks with episodes of respiratory failure per week in past 12 months):

1

2

3

4 or more

2. HAS THE VETERAN HAD ANY ASTHMA EXACERBATIONS IN THE PAST 12 MONTHS?
YES

NO

(If "Yes," describe frequency and severity of exacerbations):

(Indicate frequency of physician visits for required care of exacerbations over past 12 months):

Less frequently than monthly

At least monthly

PART B - BRONCHIECTASIS
1. INDICATE ANY FINDINGS, SIGNS AND SYMPTOMS THAT ARE ATTRIBUTABLE TO BRONCHIECTASIS:
Productive cough (If checked, indicate frequency and severity of productive cough (check all that apply)):
Intermittent
Daily with purulent sputum at times
Daily with blood-tinged sputum at times
Near constant with purulent sputum
Other, describe:
Acute infection

(If checked, indicate number of infections requiring a prolonged course of antibiotics (lasting 4 to 6 weeks) in the past 12 months):
0

1

2

3

4 or more

Requiring antibiotic usage almost continuously
Anorexia (If checked, describe):
Weight loss (If checked, provide baseline weight:

and current weight:
(Note - For VA purposes, baseline weight is the average weight for 2-year period preceding onset of disease)

)

Frank hemoptysis (If checked, describe):
Other, describe:
2. HAS THE VETERAN HAD ANY INCAPACITATING EPISODES OF INFECTION DUE TO BRONCHIECTASIS?

(NOTE: For VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician)
YES
NO (If "Yes," indicate total duration of incapacitating episodes of infection in past 12 months):
0 to no more than 2 weeks
2 to no more than 4 weeks
4 to no more than 6 weeks
At least 6 weeks or more

PART C - SARCOIDOSIS
1. DOES THE VETERAN HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO SARCOIDOSIS?
YES

NO

(If, "Yes," check all that apply):

No physiologic impairment
No symptoms
Persistent symptoms (If checked, describe):
Chronic hilar adenopathy
Stable lung infiltrates
Pulmonary involvement
Progressive pulmonary disease (If checked, describe):
Cardiac involvement with congestive heart failure
Fever (If checked, describe):
Night sweats (If checked, describe):
Weight loss (If checked, provide baseline weight:

and current weight:
(NOTE: For VA purposes, baseline weight is the average weight for a 2-year period preceding onset of disease)

)

Other, describe:
VA FORM 21-0960L-1, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

PART C - SARCOIDOSIS (Continued)
2. INDICATE STAGE DIAGNOSED BY X-RAY FINDINGS:
Stage 1: Bihilar lymphadenopathy
Stage 2: Bihilar lymphadenopathy and reticulonodular infiltrates
Stage 3: Bilateral pulmonary infiltrates
Stage 4: Fibrocystic sarcoidosis typically with upward hilar retraction, cystic and bullous changes
3. DOES THE VETERAN HAVE OPTHALMOLOGIC, RENAL, CARDIAC, NEUROLOGIC, OR OTHER ORGAN SYSTEM INVOLVEMENT DUE TO SARCOIDOSIS?
YES

(If "Yes," also complete appropriate additional Questionnaires)

NO

PART D - PULMONARY EMBOLISM AND RELATED DISEASES
1. SELECT THE STATEMENT(S) THAT BEST DESCRIBE THE VETERAN'S PULMONARY VASCULAR DISEASE OR PULMONARY EMBOLISM CONDITION

(Check all that apply):

Asymptomatic, following resolution of pulmonary thromboembolism
Symptomatic, following resolution of acute pulmonary embolism
Chronic pulmonary thromboembolism requiring anticoagulant therapy
Following inferior vena cava surgery
Chronic pulmonary thromboembolism
Pulmonary hypertension secondary to other obstructive disease of pulmonary arteries or veins with evidence of right ventricular hypertrophy or cor pulmonale
Other, describe:

PART E - BACTERIAL LUNG INFECTION
1. INDICATE CURRENT STATUS OF THE VETERAN'S BACTERIAL INFECTION OF THE LUNG (including actinomycosis, nocardiosis and chronic lung abscess):
INACTIVE

ACTIVE

2. DOES THE VETERAN HAVE ANY FINDINGS, SIGNS AND SYMPTOMS ATTRIBUTABLE TO A BACTERIAL INFECTION OF THE LUNG OR CHRONIC LUNG ACCESS?
YES

NO

(If "Yes," check all that apply):

Fever
Night sweats

and current weight:

Weight loss (If checked, provide baseline weight:

)

(NOTE: For VA purposes, baseline weight is the average weight for 2-year period preceding onset of disease)
Hemoptysis
Other, describe:

PART F - MYCOTIC LUNG DISEASES
1. INDICATE STATUS OF MYCOTIC LUNG DISEASE (including histoplasmosis of lung, coccidioidomycosis, blastomycosis, cryptococcosis, aspergillosis, or
mucormycosis) (Check all that apply):
No symptoms
Chronic pulmonary mycosis
Healed and inactive mycotic lesions
Occasional productive cough
Occasional minor hemoptysis
Requires suppressive therapy
Fever
Night sweats
Weight loss (If checked, provide baseline weight:

and current weight:
(NOTE: For VA purposes, baseline weight is the average weight for a 2-year period preceding onset of disease)

)

Massive hemoptysis
Other, describe:

PART G - PNEUMOTHORAX
1. INDICATE THE TYPE OF PNEUMOTHORAX, TREATMENT AND RESIDUAL CONDITIONS, IF ANY (Check all that apply):
Spontaneous total pneumothorax
Spontaneous partial pneumothorax
Traumatic total pneumothorax
Traumatic partial pneumothorax
Resulting in hospitalization (If checked, provide date of hospital admission

and date of discharge

)

Resulting in residual conditions (If checked, describe):
Other, describe:

VA FORM 21-0960L-1, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

SECTION IV - PULMONARY CONDITIONS (Continued)
PART H - GUNSHOT/FRAGMENT WOUND
1. SELECT THE STATEMENT(S) THAT BEST DESCRIBE THE VETERAN'S GUNSHOT OR FRAGMENT WOUND OR THE PLEURAL CAVITY AND RESIDUALS, IF ANY

(Check all that apply):

Bullet or missile retained in lung
Pain or discomfort on exertion
Scattered rales
Some limitation of excursion of diaphragm or of lower chest expansion
Other, describe:

(NOTE: If any muscles (other than those which control respiration) are affected by this injury, ALSO complete VA Form 21-0960M-10, Muscle Injury Disability
Benefits Questionnaire)
PART I - CARDIOPULMONARY COMPLICATIONS
1. DOES THE VETERAN'S RESPIRATORY CONDITION RESULT IN CARDIOPULMONARY COMPLICATIONS SUCH AS COR PULMONALE, RIGHT VENTRICULAR
HYPERTROPHY OR PULMONARY HYPERTENSION?
YES

(If "Yes,"check all that apply):

NO

Cor pulmonale (right heart failure)
Right ventricular hypertrophy
Pulmonary hypertension (shown by echocardiogram or cardiac catheterization; report test results in Section 15, Diagnostic Testing)
Other, describe:
2. IF THE VETERAN HAS MORE THAN ONE RESPIRATORY CONDITION, INDICATE WHICH CONDITION IS PREDOMINANTLY RESPONSIBLE FOR THE EPISODES
OF RESPIRATORY FAILURE:

PART J - RESPIRATORY FAILURE
1. PROVIDE DATES AND DESCRIBE THE VETERAN'S EPISODES OF ACUTE RESPIRATORY FAILURE:

2. IF THE VETERAN HAS MORE THAN ONE RESPIRATORY CONDITION, INDICATE WHICH CONDITION IS PREDOMINANTLY RESPONSIBLE FOR THE EPISODES
OF RESPIRATORY FAILURE:

PART K - TUMORS AND NEOPLASMS
1. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS?
YES

(If "Yes," complete the following section)

NO

2. IS THE NEOPLASM:
BENIGN

MALIGNANT

3. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM OR
METASTASES?
YES

NO; WATCHFUL WAITING

(If, "Yes," indicate type of treatment (check all that apply)):
Treatment completed; currently in watchful waiting status
Surgery (If checked, describe:
Radiation therapy (Date of most recent treatment:

Date(s) of surgery:

)

Date of completion of treatment or anticipated date of completion:

)

Antineoplastic chemotherapy (Date of most recent treatment:

Date of completion of treatment or anticipated date of completion:

)

Other therapeutic procedure (If checked, describe procedure):

(Date of most recent procedure):
Other therapeutic treatment (If checked, describe treatment):
(Date of completion of treatment or anticipated date of completion):
4. DOES THE VETERAN CURRENTLY HAVE ANY RESIDUAL CONDITIONS OR COMPLICATIONS DUE TO THE NEOPLASM (including metastases) OR ITS
TREATMENT, OTHER THAN THOSE ALREADY DOCUMENTED?
YES

NO

(If "Yes," list residual conditions and complications (brief summary):

5. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DESCRIBE USING
THE ABOVE FORMAT:

VA FORM 21-0960L-1, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

PART L - OTHER PERTINENT PHYSICAL FINDINGS, SCARS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
1. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN THE
DIAGNOSIS SECTION?
YES

NO

IF "YES," ARE ANY OF THESE SCARS PAINFUL AND/OR UNSTABLE; HAVE A TOTAL AREA EQUAL TO OR GREATER THAN 39 SQUARE CM
6 square inches); OR ARE LOCATED ON THE HEAD, FACE, OR NECK?
NO

YES

IF "YES," ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE (DBQ).
IF "NO," PROVIDE LOCATION AND MEASUREMENTS OF SCAR IN CENTIMETERS.
LOCATION:__________________________________ MEASUREMENTS: Length_____________ cm X width _____________ cm.
NOTE: An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar. If there are multiple scars, enter additional locations
and measurements in the "Remarks" section. It is not necessary to also complete a Scars/Disfigurement DBQ.
2. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
YES

NO

(If "Yes," describe (brief summary):

SECTION V - DIAGNOSTIC TESTING
NOTE: If diagnostic test results are in the medical record and reflect the veteran's current respiratory condition, repeat testing is not required.
5A. HAVE IMAGING STUDIES OR PROCEDURES BEEN PERFORMED? (For VA purposes, imaging studies are not required for many respiratory conditions)
YES

NO

(If "Yes," check all that apply):

Chest x-ray

Date:

Results:

Magnetic resonance imaging (MRI)

Date:

Results:

Computed tomography (CT)

Date:

Results:

High resolution computed tomography to evaluate
interstitial lung disease such as asbestosis (HRCT)

Date:

Results:

Bronchoscopy

Date:

Results:

Biopsy

Date:

Results:

Other, describe:

Date:

Results:

5B. HAS PULMONARY FUNCTION TESTING (PFT) BEEN PERFORMED?
YES

NO

(If "Yes," do PFT results reported below reflect the veteran's current pulmonary function?)
YES

NO

MOST RESPIRATORY CONDITIONS REQUIRE PULMONARY FUNCTION TESTING, SINCE PFT RESULTS REPRESENT A MAJOR BASIS FOR THEIR EVALUATION.
HOWEVER, PULMONARY FUNCTION TESTING IS NOT REQUIRED IN ALL INSTANCES. FOR VA PURPOSES, IF THE VETERAN HAS ANY OF THE FOLLOWING
CONDITIONS, PFTs ARE NOT REQUIRED. IF PFTs HAVE NOT BEEN COMPLETED, INDICATE REASON:
Veteran requires outpatient oxygen therapy
Veteran has had 1 or more episodes of acute respiratory failure
Veteran has been diagnosed with cor pulmonale, right ventricular hypertrophy or hypertension
Veteran has had exercise capacity testing and results are 20 ml/kg/min or less
Other, describe:
5C. PFT RESULTS:
Date of test:
Pre-bronchodilator:

Post-bronchodilator, if indicated:

FVC:

% predicted

FVC:

% predicted

FEV-1:

% predicted

FEV-1:

% predicted

FEV-1/FVC:
DLCO:

%

FEV-1/FVC:

%

% predicted

5D. WHICH TEST RESULT MOST ACCURATELY REFLECTS THE VETERAN'S LEVEL OF DISABILITY (Based on the condition that is being evaluated for this report)?
THIS QUESTION IS IMPORTANT FOR VA PURPOSES.
FVC % predicted
FEV-1 % predicted
FEV-1/FVC
DLCO
5E. IF POST-BRONCHODILATOR TESTING HAS NOT BEEN COMPLETED, INDICATE REASON:
Pre-bronchodilator results are normal
Not indicated for veteran's condition
Not indicated in veteran's particular case (If checked, provide reason):
Other, describe:
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PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

SECTION V - DIAGNOSTIC TESTING (Continued)

5F. IF DIFFUSION CAPACITY OF THE LUNG FOR CARBON MONOXIDE BY THE SINGLE BREATH METHOD (DLCO) TESTING HAS NOT BEEN COMPLETED,
INDICATE REASON:
Not indicated for veteran's condition
Not indicated in veteran's particular case
Not valid for veteran's particular case
Other, describe:
5G. DOES THE VETERAN HAVE MULTIPLE RESPIRATORY CONDITIONS?
YES

NO

(If "Yes," list conditions and indicate which condition is predominantly responsible for the limitation in pulmonary function, if any limitation is present):

5H. HAS EXERCISE CAPACITY TESTING BEEN PERFORMED?
YES

NO

(If "Yes,"complete the following):

Maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation)
Maximum oxygen consumption of 15-20 ml/kg/min (with cardiorespiratory limit)
5I. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO

(If "Yes," describe (brief summary)):

SECTION VI - FUNCTIONAL IMPACT
6. DOES THE VETERAN'S RESPIRATORY CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe impact of each of the veteran's respiratory conditions, providing one or more examples):

SECTION VII - REMARKS
7. REMARKS (If any)

SECTION VIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
8A. PHYSICIAN'S SIGNATURE
8D. PHYSICIAN'S PHONE/FAX NUMBERS

8B. PHYSICIAN'S PRINTED NAME
8E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER

8C. DATE SIGNED
8F. PHYSICIAN'S ADDRESS

NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.

IMPORTANT - Physician please fax the completed form to:
(VA Regional Office FAX No.)
NOTE - A list of VA Regional Office FAX Numbers can be found at www.benefits.va.gov/disabilityexams or obtained by calling 1-800-827-1000.
PRIVACY ACT NOTICE: 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 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research
studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and
delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58/VA21/22/28, Compensation,
Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. VA uses
your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account
information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide
his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is
considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information
submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete the 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.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to
get information on where to send comments or suggestions about this form.
VA FORM 21-0960L-1, XXX XXXX

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