VA Form 21-0960D-1 "Oral and Dental Conditions Including Mouth, Lips and Tongue (Other Than Temporomandibular Joint Conditions) Disability Benefits Questionnaire"

What Is VA Form 21-0960D-1?

This is a legal form that was released by the U.S. Department of Veterans Affairs on September 1, 2016 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2016;
  • The latest available edition released by the U.S. Department of Veterans Affairs;
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Download a fillable version of VA Form 21-0960D-1 by clicking the link below or browse more documents and templates provided by the U.S. Department of Veterans Affairs.

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Download VA Form 21-0960D-1 "Oral and Dental Conditions Including Mouth, Lips and Tongue (Other Than Temporomandibular Joint Conditions) Disability Benefits Questionnaire"

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OMB Approved No. 2900-0781
Respondent Burden: 15 Minutes
Expiration Date: 09/30/2019
ORAL AND DENTAL CONDITIONS INCLUDING MOUTH, LIPS AND TONGUE
(OTHER THAN TEMPOROMANDIBULAR JOINT CONDITIONS)
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 FORM.
(First, Middle Initial, Last)
NAME OF PATIENT/VETERAN
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
(This is the condition the veteran is
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN ORAL OR DENTAL CONDITION?
claiming or for which an exam has been requested)
(If "Yes," complete Item 1B)
YES
NO
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.
(check all that apply)
1B. SELECT THE VETERAN'S CONDITION
LOSS OF ANY PORTION OF MANDIBLE
ICD Code:
Date of diagnosis:
(for reasons other than periodontal disease or edentulous atrophy)
LOSS OF ANY PORTION OF MAXILLA
ICD Code:
Date of diagnosis:
(for reasons other than periodontal disease or edentulous atrophy)
MALUNION OR NONUNION OF MANDIBLE
ICD Code:
Date of diagnosis:
MALUNION OR NONUNION OF MAXILLA
ICD Code:
Date of diagnosis:
(for reasons other than periodontal disease, or other
LOSS OF TEETH
ICD Code:
Date of diagnosis:
routine dental maladies: this is intended for loss of teeth
due to service-related trauma)
(TMJD) (If checked,
TEMPOROMANDIBULAR JOINT DISORDER
ICD Code:
Date of diagnosis:
complete the VA Form 21-0960M-15, Temporomandibular Joint
Conditions Disability Benefits Questionnaire in lieu of this questionnaire
if that is the veteran's only condition. If the veteran has a TMJD condition
AND additional oral or dental conditions, complete this questionnaire and
ALSO complete VA Form 21-0960M-15)
LIMITATION OF MOTION OF THE TEMPOROMANDIBULAR JOINT
ICD Code:
Date of diagnosis:
(If checked, complete this
DUE TO CAUSES OTHER THAN TMJD
questionnaire and ALSO complete VAF Form 21-0960M-15,
Temporomandibular Joint Conditions Disability Benefits Questionnaire)
ANATOMICAL LOSS OR INJURY OF THE MOUTH, LIPS OR TONGUE
ICD Code:
Date of diagnosis:
OSTEOMYELITIS, OSTEORADIONECROSIS OR BISPHOSPHONATE-
ICD Code:
Date of diagnosis:
RELATED OSTEONECROSIS OF THE JAW
(If checked, specify):
ORAL NEOPLASM
ICD Code:
Date of diagnosis:
(If this is the ONLY diagnosis checked, proceed
PERIODONTAL DISEASE
ICD Code:
Date of diagnosis:
to the signature section at the end of this form (for VA purposes this
disease is not considered disabling)
(specify):
OTHER
Other diagnosis #1
ICD Code:
Date of diagnosis:
Other diagnosis #2
ICD Code:
Date of diagnosis:
1C. IF ADDITIONAL DIAGNOSES THAT PERTAIN TO ORAL OR DENTAL CONDITIONS, LIST USING ABOVE FORMAT:
NOTE: This questionnaire is appropriate for bone loss due to trauma or disease such as osteomyelitis and not to the loss of the alveolar process as a result of periodontal
disease, edentuious atrophy since such loss is not considered disabling. This is intended for loss of teeth due to service-related trauma.
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
(including onset and course)
3A. MEDICAL/DENTAL HISTORY
OF THE VETERAN'S ORAL AND/OR DENTAL CONDITION:
21-0960D-1
SUPERSEDES VA FORM 21-0960D-1, OCT 2012,
Page 1
VA FORM
WHICH WILL NOT BE USED.
SEP 2016
OMB Approved No. 2900-0781
Respondent Burden: 15 Minutes
Expiration Date: 09/30/2019
ORAL AND DENTAL CONDITIONS INCLUDING MOUTH, LIPS AND TONGUE
(OTHER THAN TEMPOROMANDIBULAR JOINT CONDITIONS)
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 FORM.
(First, Middle Initial, Last)
NAME OF PATIENT/VETERAN
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
(This is the condition the veteran is
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN ORAL OR DENTAL CONDITION?
claiming or for which an exam has been requested)
(If "Yes," complete Item 1B)
YES
NO
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.
(check all that apply)
1B. SELECT THE VETERAN'S CONDITION
LOSS OF ANY PORTION OF MANDIBLE
ICD Code:
Date of diagnosis:
(for reasons other than periodontal disease or edentulous atrophy)
LOSS OF ANY PORTION OF MAXILLA
ICD Code:
Date of diagnosis:
(for reasons other than periodontal disease or edentulous atrophy)
MALUNION OR NONUNION OF MANDIBLE
ICD Code:
Date of diagnosis:
MALUNION OR NONUNION OF MAXILLA
ICD Code:
Date of diagnosis:
(for reasons other than periodontal disease, or other
LOSS OF TEETH
ICD Code:
Date of diagnosis:
routine dental maladies: this is intended for loss of teeth
due to service-related trauma)
(TMJD) (If checked,
TEMPOROMANDIBULAR JOINT DISORDER
ICD Code:
Date of diagnosis:
complete the VA Form 21-0960M-15, Temporomandibular Joint
Conditions Disability Benefits Questionnaire in lieu of this questionnaire
if that is the veteran's only condition. If the veteran has a TMJD condition
AND additional oral or dental conditions, complete this questionnaire and
ALSO complete VA Form 21-0960M-15)
LIMITATION OF MOTION OF THE TEMPOROMANDIBULAR JOINT
ICD Code:
Date of diagnosis:
(If checked, complete this
DUE TO CAUSES OTHER THAN TMJD
questionnaire and ALSO complete VAF Form 21-0960M-15,
Temporomandibular Joint Conditions Disability Benefits Questionnaire)
ANATOMICAL LOSS OR INJURY OF THE MOUTH, LIPS OR TONGUE
ICD Code:
Date of diagnosis:
OSTEOMYELITIS, OSTEORADIONECROSIS OR BISPHOSPHONATE-
ICD Code:
Date of diagnosis:
RELATED OSTEONECROSIS OF THE JAW
(If checked, specify):
ORAL NEOPLASM
ICD Code:
Date of diagnosis:
(If this is the ONLY diagnosis checked, proceed
PERIODONTAL DISEASE
ICD Code:
Date of diagnosis:
to the signature section at the end of this form (for VA purposes this
disease is not considered disabling)
(specify):
OTHER
Other diagnosis #1
ICD Code:
Date of diagnosis:
Other diagnosis #2
ICD Code:
Date of diagnosis:
1C. IF ADDITIONAL DIAGNOSES THAT PERTAIN TO ORAL OR DENTAL CONDITIONS, LIST USING ABOVE FORMAT:
NOTE: This questionnaire is appropriate for bone loss due to trauma or disease such as osteomyelitis and not to the loss of the alveolar process as a result of periodontal
disease, edentuious atrophy since such loss is not considered disabling. This is intended for loss of teeth due to service-related trauma.
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
(including onset and course)
3A. MEDICAL/DENTAL HISTORY
OF THE VETERAN'S ORAL AND/OR DENTAL CONDITION:
21-0960D-1
SUPERSEDES VA FORM 21-0960D-1, OCT 2012,
Page 1
VA FORM
WHICH WILL NOT BE USED.
SEP 2016
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION III - MEDICAL HISTORY (Continued)
3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S ORAL AND/OR DENTAL CONDITION?
YES
NO
If "Yes," list only those medications required for the veteran's oral and/or dental condition)
SECTION IV - DENTAL AND ORAL CONDITIONS
4. DOES THE VETERAN HAVE ANY OF THE FOLLOWING DENTAL OR ORAL CONDITIONS?
(If "No," proceed to Section V)
YES
NO
(If "Yes," check all that apply)
(anatomical loss or bony injury) (If checked, complete Part A below.)
Mandible
(anatomical loss or bony injury) (If checked, complete Part B below.)
Maxilla
(anatomical loss or bony injury leading to loss of any teeth) (If checked, complete Part C below.)
Teeth
(anatomical loss or injury) (If checked, complete Part D below.)
Mouth, lips, tongue and disfiguring scars to the mouth or lips
(If checked, complete Part E below.)
Osteomyelitis/osteoradionecrosis/bisphposphonate-related osteonecrosis of the jaw
(If checked, complete Part F below.)
Tumors or neoplasms
(If checked, complete Part G below.)
Other dental or oral conditions, pertinent physical findings or scars due to dental or oral conditions
PART A - MANDIBLE, INCLUDING ANATOMICAL LOSS OR BONY INJURY (NOT DUE TO EDENTULOUS ATROPHY OR PERIODONTAL DISEASE)
(not due to edentulous atrophy or periodontal disease)
1. HAS THE VETERAN LOST ANY PART OF THE MANDIBLE OR MANDIBULAR RAMUS
?
(If "Yes," indicate severity (check all that apply))
YES
NO
Loss of approximately 1/2 of the mandible, not involving the temporomandibular articulation
Loss of approximately 1/2 of the mandible, involving the temporomandibular articulation
Complete loss of the mandible between angles
(If checked, indicate side):
Loss of less than 1/2 the substance of mandibular ramus, not involving loss of continuity
Right
Left
Both
(If checked, indicate side):
Loss of whole or part of mandibular ramus, without loss of temporomandibular articulation
Right
Left
Both
(If checked, indicate side):
Loss of whole or part of mandibular ramus, involving loss of temporomandibular articulation
Right
Left
Both
(describe):
Other
(condyloid process)
2. HAS THE VETERAN LOST EITHER CONDYLOID
OF THE MANDIBLE?
(If "Yes," indicate side):
YES
NO
Right
Left
Both
3. HAS THE VETERAN LOST EITHER CORONOID PROCESS OF THE MANDIBLE?
(If "Yes," indicate side):
YES
NO
Right
Left
Both
4. HAS THE VETERAN HAD AN INJURY RESULTING IN MALUNION OR NONUNION OF THE MANDIBLE?
(If "Yes," indicate severity):
YES
NO
Malunion with slight displacement
Malunion with moderate displacement
Malunion with severe displacement
Nonunion, moderate
Nonunion, severe
(describe):
Other
NOTE - The assessment of the severity of malunion or nonunion of the mandible is dependent upon degree of motion and relative loss of masticatory function.
PART B - MAXILLA, INCLUDING ANATOMICAL LOSS OR BONY INJURY (NOT DUE TO ENDENTULOUS ATROPHY OR PERIODONTAL DISEASE)
(Not due to endentulous atrophy or periodontal disease)
1. HAS THE VETERAN LOST ANY PART OF THE MAXILLA?
(If "Yes," indicate severity)
YES
NO
Loss of less than 25%
Loss of 25 to 50%
Loss of more than 50%
2. IF THE VETERAN HAS LOST ANY PART OF THE MAXILLA, IS THE LOSS REPLACEABLE BY PROSTHESIS?
YES
NO
NOT APPLICABLE
3. HAS THE VETERAN LOST ANY PART OF THE HARD PALATE?
(If "Yes," indicate severity)
YES
NO
Loss of less than 50%
Loss of 50% or more
4. IF THE VETERAN HAS LOST ANY PART OF THE HARD PALATE, IS THE LOSS REPLACEABLE BY PROSTHESIS?
YES
NO
NOT APPLICABLE
5. HAS THE VETERAN HAD AN INJURY RESULTING IN MALUNION OR NONUNION OF THE MAXILLA?
(If "Yes," indicate severity)
YES
NO
Malunion or nonunion with slight displacement
Malunion or nonunion with moderate displacement
Malunion or nonunion with severe displacement
Page 2
VA FORM 21-0960D-1, SEP 2016
PATIENT/VETERAN'S SOCIAL SECURITY NO.
(Continued)
SECTION IV - DENTAL AND ORAL CONDITIONS
PART C - TEETH, INCLUDING ANATOMICAL LOSS OR BONY INJURY LEADING TO LOSS OF ANY TEETH
(OTHER THAN THAT DUE TO THE LOSS OF THE ALVEOLAR PROCESS AS A RESULT OF PERIODONTAL DISEASE)
1. IS THE LOSS OF TEETH DUE TO LOSS OF SUBSTANCE OF BODY OF MAXILLA OR MANDIBLE WITHOUT LOSS OF CONTINUITY?
YES
NO
2. IS THE LOSS OF TEETH DUE TO TRAUMA OR DISEASE (SUCH AS OSTEOMYELITIS?)
(If "Yes," describe):
YES
NO
3. CAN THE MASTICATORY SURFACES BE RESTORED BY SUITABLE PROSTHESIS?
(If "Yes," describe):
YES
NO
(Check all that apply):
4. INDICATE THE EXTENT OF LOSS OF TEETH
Upper Teeth
No missing teeth
All right posterior missing
Other, describe:
All posterior teeth missing bilaterally
All right anterior missing
All anterior teeth missing bilaterally
All left posterior missing
All upper teeth missing
All left anterior missing
Lower Teeth
No missing teeth
All right posterior missing
Other, describe:
All posterior teeth missing bilaterally
All right anterior missing
All anterior teeth missing bilaterally
All left posterior missing
All lower teeth missing
All left anterior missing
5. LIST MISSING TEETH BY NUMBER:
PART D - MOUTH, LIPS, TONGUE AND DISFIGURING SCARS TO THE MOUTH OR LIPS (ANATOMICAL LOSS OR INJURY)
1. DOES THE VETERAN HAVE ANY DISFIGURING SCARS TO THE MOUTH OR LIPS?
(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
YES
NO
2. DOES THE VETERAN HAVE A MOUTH INJURY THAT RESULTS IN IMPAIRMENT OF MASTICATION?
(If "Yes," describe):
YES
NO
3. DOES THE VETERAN HAVE PARTIAL OR COMPLETE LOSS OF THE TONGUE?
(If "Yes," indicate severity)
YES
NO
Loss of less than 1/2 of tongue
Loss of 1/2 or more of tongue
4. DOES THE VETERAN HAVE A SPEECH IMPAIRMENT CAUSED BY PARTIAL OR COMPLETE LOSS OF THE TONGUE, OR BY ANY OTHER TONGUE CONDITION?
(If "Yes," indicate severity)
YES
NO
(If checked, describe):
Marked speech impairment
(If checked, describe):
Inability to communicate by speech
PART E - OSTEOMYELITIS/OSTEORADIONECROSIS/BISPHOSPHONATE-RELATED OSTEONECROSIS OF THE JAW
1. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH OSTEOMYELITIS OR OSTEORADIONECROSIS OF THE MANDIBLE?
(If "Yes," ALSO complete VA Form 21-0960M-11, Osteomyelitis Disability Benefits Questionnaire)
YES
NO
2. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH BISPHOSPHONATE-RELATED OSTEONECROSIS OF THE JAW?
(If "Yes," describe):
YES
NO
PART F - TUMORS AND NEOPLASMS
1. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES CHECKED IN SECTION I,
DIAGNOSIS?
(If "Yes," complete the following section)
YES
NO
2. IS THE NEOPLASM?
BENIGN
MALIGNANT
Page 3
VA FORM 21-0960D-1, SEP 2016
PATIENT/VETERAN'S SOCIAL SECURITY NO.
(Continued)
SECTION IV - DENTAL AND ORAL CONDITIONS
(Continued)
PART F - TUMORS AND NEOPLASMS
3. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM
SECTION?
YES
NO; WATCHFUL WAITING
(If "Yes," indicate type of treatment the veteran is currently undergoing or has completed (check all that apply)):
Treatment completed; currently in watchful waiting status
(If checked, describe):
Surgery
Date(s) of surgery:
Radiation therapy
Date of most recent treatment:
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:
(including metastases)
4. DOES THE VETERAN CURRENTLY HAVE ANY RESIDUAL CONDITIONS OR COMPLICATIONS DUE TO THE NEOPLASM
OR ITS
TREATMENT, OTHER THAN THOSE ALREADY DOCUMENTED IN THE REPORT ABOVE?
(If "Yes," list residual conditions and complications (brief summary)):
YES
NO
5. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS,
DESCRIBE USING THE ABOVE FORMAT:
PART G - OTHER PERTINENT PHYSICAL FINDINGS, SCARS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
1. DOES THE VETERAN HAVE ANY SCARS
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?
YES
NO
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?
(If "Yes," describe (brief summary):
YES
NO
SECTION V - DIAGNOSTIC TESTING
NOTE - If diagnostic test results are in the medical record and reflect the veteran's current oral or dental condition, repeat testing is not required.
5A. HAVE IMAGING STUDIES OR PROCEDURES BEEN PERFORMED?
YES
NO
(If "Yes," check all that apply):
Panographic/intraoral imaging to demonstrate loss of teeth,
Date:
Results:
mandible or maxilla
Other:
Date:
Results:
5B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
(If "Yes," provide type of test or procedure, date and results (brief summary)):
YES
NO
Page 4
VA FORM 21-0960D-1, SEP 2016
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION VI - FUNCTIONAL IMPACT
6. DOES THE VETERAN'S ORAL OR DENTAL CONDITION IMPACT HIS OR HER ABILITY TO WORK?
(If "Yes," describe impact of each of the veteran's oral or dental condition(s), providing one or more examples):
YES
NO
SECTION VII - REMARKS
(If any)
7. REMARKS
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
8B. PHYSICIAN'S PRINTED NAME
8C. DATE SIGNED
8D. PHYSICIAN'S PHONE/FAX NUMBERS
8E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER 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 21-0960D-1, SEP 2016
Page 5