VA Form 21-0960c-6 "Narcolepsy Disability Benefits Questionnaire"

What Is VA Form 21-0960c-6?

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;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;

Download a fillable version of VA Form 21-0960c-6 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 21-0960c-6 "Narcolepsy Disability Benefits Questionnaire"

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OMB Approved No. 2900-0781
Respondent Burden: 15 Minutes
Expiration Date: 09/30/2019
NARCOLEPSY 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.
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
(This is the condition the veteran is claiming or for which an
1A. DOES THE VETERAN HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH NARCOLEPSY?
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. DIAGNOSES
NARCOLEPSY
ICD code:
Date of diagnosis:
(specify):
OTHER
Other diagnosis #1:
ICD code:
Date of diagnosis:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO NARCOLEPSY, LIST USING ABOVE FORMAT:
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)
(brief summary)
3A. DESCRIBE THE HISTORY
OF THE VETERAN'S NARCOLEPSY
:
3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF NARCOLEPSY?
(If "Yes," list only those medications required for the veteran's narcolepsy):
YES
NO
SECTION IV- FINDINGS, SIGNS AND SYMPTOMS
4A. DOES THE VETERAN HAVE A CONFIRMED DIAGNOSIS OF NARCOLEPSY?
(If "Yes," complete Items 4A & 4B)
YES
NO
4B. DOES THE VETERAN REPORT ANY OF THE FOLLOWING FINDINGS, SIGNS OR SYMPTOMS?
YES
NO
(If "Yes," check all that apply):
Excessive daytime sleepiness
(strong urge to sleep followed by short nap)
Sleep attacks
(sudden loss of muscle tone while awake, resulting in brief inability to move)
Cataplexy
(inability to move on first awakening)
Sleep paralysis
Sleep onset/sleep offset hallucinations
Other
(For all checked conditions in item 4B, provide a description below):
(check all that apply):
4C. INDICATE FREQUENCY OF CATAPLECTIC (NARCOLEPTIC) EPISODES
Number of cataplectic (narcoleptic) episodes over past 6 months
0-1
2 or more
(If 2 or more over the past 6 months, indicate the "average frequency" of narcoleptic episodes):
0-4 per week
5-8 per week
9-10 per week
More than 10 per week
(If the Veteran has cataplectic (narcoleptic) episodes, provide a description below):
21-0960C-6
SUPERSEDES VA FORM 21-0960C-6, 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
NARCOLEPSY 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.
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
(This is the condition the veteran is claiming or for which an
1A. DOES THE VETERAN HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH NARCOLEPSY?
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. DIAGNOSES
NARCOLEPSY
ICD code:
Date of diagnosis:
(specify):
OTHER
Other diagnosis #1:
ICD code:
Date of diagnosis:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO NARCOLEPSY, LIST USING ABOVE FORMAT:
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)
(brief summary)
3A. DESCRIBE THE HISTORY
OF THE VETERAN'S NARCOLEPSY
:
3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF NARCOLEPSY?
(If "Yes," list only those medications required for the veteran's narcolepsy):
YES
NO
SECTION IV- FINDINGS, SIGNS AND SYMPTOMS
4A. DOES THE VETERAN HAVE A CONFIRMED DIAGNOSIS OF NARCOLEPSY?
(If "Yes," complete Items 4A & 4B)
YES
NO
4B. DOES THE VETERAN REPORT ANY OF THE FOLLOWING FINDINGS, SIGNS OR SYMPTOMS?
YES
NO
(If "Yes," check all that apply):
Excessive daytime sleepiness
(strong urge to sleep followed by short nap)
Sleep attacks
(sudden loss of muscle tone while awake, resulting in brief inability to move)
Cataplexy
(inability to move on first awakening)
Sleep paralysis
Sleep onset/sleep offset hallucinations
Other
(For all checked conditions in item 4B, provide a description below):
(check all that apply):
4C. INDICATE FREQUENCY OF CATAPLECTIC (NARCOLEPTIC) EPISODES
Number of cataplectic (narcoleptic) episodes over past 6 months
0-1
2 or more
(If 2 or more over the past 6 months, indicate the "average frequency" of narcoleptic episodes):
0-4 per week
5-8 per week
9-10 per week
More than 10 per week
(If the Veteran has cataplectic (narcoleptic) episodes, provide a description below):
21-0960C-6
SUPERSEDES VA FORM 21-0960C-6, OCT 2012,
Page 1
VA FORM
WHICH WILL NOT BE USED.
SEP 2016
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
5. 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 VI - DIAGNOSTIC TESTING
NOTE - If diagnostic test results are in the medical record and reflect the veteran's current narcolepsy condition, repeat testing is not required.
6A. HAVE ANY IMAGING STUDIES OR DIAGNOSTIC PROCEDURES BEEN PERFORMED?
(If "Yes," check all that apply)
YES
NO
(PSG)
Polysomnogram
Date:
Results:
(MSLT)
Multiple Sleep Latency Test
Date:
Results:
(CSF)
Hypocretin level in cerebrospinal fluid
Date:
Results:
(describe):
Other
Date:
Results:
6B. 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
SECTION VII - FUNCTIONAL IMPACT
7. DOES THE VETERAN'S NARCOLEPSY IMPACT HIS OR HER ABILITY TO WORK?
(If "Yes," describe impact, providing one or more examples):
YES
NO
SECTION VIII - REMARKS
(If any):
8. REMARKS
SECTION IX - PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
9A. PHYSICIAN'S SIGNATURE
9B. PHYSICIAN'S PRINTED NAME
9C. DATE SIGNED
9D. PHYSICIAN'S PHONE/FAX NUMBERS
9E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER
9F. 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.
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VA FORM 21-0960C-6, SEP 2016
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