21 0960E 1 Form – Fill Out and Use This PDF

21 0960E 1 Form PDF Details

The 21 0960E 1 form is the Diabetes Mellitus Disability Benefits Questionnaire. The VA requires this document to process diabetes disability claims. A licensed doctor or VA examiner fills it out on behalf of the veteran. The VA uses the completed form to assign a rating under 38 CFR 4.119.

Who Uses the 21 0960E 1 Form

Veterans with type 1 or type 2 diabetes linked to their military service need this form. It supports a new VA disability claim or a request for a higher rating. Veterans claiming secondary conditions caused by diabetes also need it. Common secondary conditions include nerve damage, eye problems, and kidney disease.

What the Form Asks

The 21 0960E 1 form collects details about the veteran's diabetes. The doctor records the type of diabetes and the date of diagnosis. The form asks what treatment the veteran uses: insulin, diabetes pills, or diet control only. Insulin use leads to a higher disability rating than diet control alone.

The doctor also lists any complications. The form covers these conditions:

• Nerve damage in the hands, feet, or legs
• Eye problems linked to diabetes
• Heart conditions related to diabetes
• Kidney problems caused by diabetes
• Low blood sugar episodes that needed medical care

The doctor also notes how often serious episodes occur. The form asks how diabetes limits the veteran's ability to work and carry out daily tasks.

How the VA Rates Diabetes

The VA rates diabetes under Diagnostic Code 7913. Ratings range from 10 percent to 100 percent. A veteran using diet control alone qualifies for a 10 percent rating. A veteran using insulin plus a restricted diet qualifies for 20 percent. Veterans with more serious complications or frequent episodes may qualify for 40 percent or higher. The 100 percent rating covers veterans with very frequent, severe episodes that require hospital care.

Secondary conditions get separate ratings on top of the base diabetes rating. This can raise the combined disability percentage.

Getting a Doctor to Fill Out the Form

The veteran brings a blank copy of the 21 0960E 1 form to a treating doctor. The doctor reviews the medical records and fills out all sections. The completed form goes with the rest of the disability claim package. Veterans can also request a VA medical exam. In that case, a VA examiner fills out the form during the appointment.

After You Submit the Form

The VA regional office reviews the claim after receiving the form. A rating decision usually takes several months. Veterans who disagree with the decision can appeal. They file a notice of disagreement to start the process. Keeping copies of the form and all supporting records helps with any future appeal. New medical evidence can support a supplemental claim if the initial rating is too low.

Other VA Disability Forms

Veterans with multiple conditions often need more than one form. The VA Form 21-0960C-8 covers heart conditions that can result from long-term diabetes. The VA Form 21-0960M-9 covers muscle and joint conditions. A disability evaluation form helps document other service-connected conditions. Our disability questionnaire template provides guidance for completing VA disability paperwork.