Ebb Form 766 R PDF Details

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QuestionAnswer
Form NameEbb Form 766 R
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesform 766 army application form, 766 nonappropriated disability application, form 766 nonappropriated form, ebb form 766 disability

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U.S. Army Nonappropriated Fund

Disability Application

EBB Form 766-R

CONTROL NUMBER: GAC 3730

EMPLOYER: The form should be given to the employee with instructions to mail it when completed by the claimant and the Attending Physician to the U.S. Army Employee Benefits Branch, P.O. Box 107, Arlington, Virginia 22210-0107.

PART A (to be completed by Employee)

EMPLOYEE: (1) Please fill out and sign this portion of your Application for Group Life Insurance Disability Benefits and/or Retirement Disability Benefits and/or 401(k) Savings Plan Disability Benefits.(IMPORTANT) - Failure to fully answer all questions will cause delay in the claim processing. Should you need assistance in completing this form, contact your Employer. (2) When completed and signed by you, forward to your Attending Physician with instructions to Complete Part C and forward to the Employee Benefits Branch at the address above.

l. LAST NAME

 

 

 

FIRST NAME

MI SEX

SOCIAL SECURITY #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. DATE OF BIRTH

 

MARRIED

 

 

 

NUMBER OF CHILDREN

DEPENDENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UPON YOU FOR SUPPORT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.MAILING ADDRESS (No., Street, Apt. No., P.O. Box or Rural Route) (City) (State) (Zip Code) TELEPHONE #

4.DESCRIBE THE DUTIES OF YOUR USUAL JOB IN YOUR OWN WORDS:

JOB TITLE YOUR EMPLOYER

5.DID YOUR USUAL JOB INVOLVE:

A. THE USE OF MACHINES, TOOLS, OR EQUIPMENT?

B. TECHNICAL KNOWLEDGE OR SPECIAL SKILLS?

C. ANY SUPERVISORY RESPONSIBILITIES?

D. TRAVEL?

PLEASE EXPLAIN ALL YES ANSWERS:

6.DESCRIBE THE KIND AND AMOUNT OF PHYSICAL ACTIVITY INVOLVED IN YOUR JOB DURING A TYPICAL WORK DAY (SELECT NUMBER OF HOURS IN A DAY THAT YOU PERFORM THESE ACTIONS AT WORK).

LIFTING AND CARRYING (DESCRIBE WHAT WAS LIFTED, HOW HEAVY IT WAS, HOW OFTEN IT WAS LIFTED AND HOW FAR IT WAS CARRIED).

7.HOW DOES YOUR ILLNESS OR INJURY NOW PREVENT YOU FROM PERFORMING YOUR USUAL DUTIES AS DESCRIBED

IN ITEMS 4, 5 & 6?

8a. LIST ANY SKILLS WHICH YOU MAY HAVE AS A RESULT OF PRIOR EMPLOYMENT, TRAINING OR EDUCATION, OR MILITARY SERVICE:

8b. LIST LAST YEAR OF SCHOOL COMPLETED:

EBB Form 766-R (APR 2000)

Page 1 of 5

9.BEFORE YOU STOPPED WORKING, DID YOUR ILLNESS OR INJURY CAUSE YOU TO CHANGE:

a.YOUR JOB OR DUTIES?

b.YOUR HOURS OF WORK?

c. YOUR ATTENDANCE?

(EXPLAIN HOW YOUR CONDITION CAUSED THESE CHANGES AND SHOW THE DATES THE CHANGES WERE MADE.)

10.BRIEFLY DESCRIBE YOUR INJURY OR ILLNESS THAT PREVENTS, OR HAS PREVENTED YOU FROM WORKING:

11.IF CONDITION DUE TO INJURY, PLEASE INDICATE THE FOLLOWING:

DATE OF INJURY

WHERE DID IT OCCUR?

12.DESCRIBE HOW ACCIDENT OCCURRED:

13.WHAT WAS YOUR LAST DAY OF WORK BECAUSE OF THIS DISABILIT ARE YOU STILL DISABLED?

14.IF YOU ARE NO LONGER DISABLED, ENTER DATE YOU WERE AGAIN DATE OF FIRST TREATMENT

 

 

TO WORK (MONTH, DAY, YEAR)

 

 

 

 

 

 

 

 

FOR THIS ILLNESS OR INJURY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15.

 

LIST THE NAME, ADDRESS AND TELEPHONE

NUMBER OF THE DOCTOR WHO HAS YOUR LATEST MEDICAL RECORDS.

 

 

 

IF YOU HAVE NO DOCTOR, CHECK HERE

______

 

 

 

 

 

 

 

 

 

 

 

 

NAME

_______________________________________

 

AREA CODE & TEL NO.

_________________

 

 

 

ADDRESS

 

 

 

 

____________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16.

 

HOW OFTEN DO YOU SEE THIS DOCTOR

DATE OF FIRST VISIT

 

 

DATE

OF LAST VISIT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17.

 

REASONS FOR VISITS

 

 

TYPE OF TREATMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

RECEIVED:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18.HAVE YOU SEEN ANY OTHER DOCTOR SINCE YOUR ILLNESS OR INJURY BEGAN? IF "YES" SHOW THE FOLLOWING:

 

 

NAME

_______________________________________

 

 

AREA CODE & TEL NO._________________

 

 

ADDRESS

____________________________________________________________________

 

 

19.

 

HOW OFTEN DO YOU SEE THIS

DOCTOR

DATE OF FIRST VISIT

 

DATE

OF LAST VISIT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20.

 

REASONS FOR VISITS

 

 

 

TYPE OF TREATMENT

 

 

 

 

 

 

 

 

 

 

RECEIVED:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21. HAS YOUR DOCTOR TOLD YOU TO RESTRICT YOUR ACTIVITIES IN ANY WAY?

IF "YES", GIVE NAME OF DOCTOR AND STATE WHAT HE/SHE TOLD YOU ABOUT RESTRICTING YOUR ACTIVITIES

EBB FORM 766-R(APR 2000)

Page 2 of 5

22. CHECK ANY OF THE FOLLOWING WHICH APPLY TO YOU:

CONFINED IN A HOSPITAL OR OTHER MEDICAL INSTITUTION._____

CONFINED TO A BED OR WHEEL CHAIR AT HOME.____

NONE OF THE ABOVE BUT UNABLE TO GO OUTSIDE.____

ABLE TO GO OUTSIDE ONLY WITH HELP OF ANOTHER PERSON OR DEVICE.____

ABLE TO GO OUTSIDE WITHOUT HELP.____

23.ARE YOUR HOME DUTIES, SOCIAL ACTIVITIES OR ABILITY TO CARE FOR YOUR PERSONAL NEEDS LIMITED IN ANY WAY?

IF "YES" DESCRIBE HOW AND WHY THEY ARE LIMITED.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24.

DO YOU EXPECT TO

RETURN TO WORK

DATE

EXPECTED TO RETURN

DATE RETURNED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25.

 

 

 

 

 

 

 

 

 

 

 

HAVE YOU BEEN SEEN BY OTHER AGENCIES FOR YOUR INJURY OR ILNESS (VA, VOCATIONAL, REHABILITATION

 

 

 

WELFARE, ETC.)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF "YES" SHOW THE

FOLLOWING:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF AGENCY

 

__________________________________________________

 

 

 

 

ADRESS OF AGENCY

_________________________________________________

 

 

 

 

YOUR CLAIM NO.

 

DATES OF VISITS

TYPE OF TREATMENT OR EXAMINATION

 

 

RECEIVED

26.HAVE YOU EVER FILED (OR DO YOU INTEND TO FILE) CLAIMS FOR DISABILITY BENEFITS UNDER ANY: WORKER'S COMPENSATION LAW OR PLAN?

SOCIAL SECURITY?

27. HAS THERE BEEN ANY DECISION OR ANY PAYMENT (TEMPORARY, PERMANENT, OR LUMP SUM) MADE ON THE CLAIMS FILED?

WORKER'S COMPENSATION CLAIM #s________________

28. ARE YOU ENTITLED TO DISABILITY BENEFITS FROM WORKER'S COMPENSATION BECAUSE OF THIS DISABILITY:

 

 

IDENTIFY

SOURCES

INSURANCE OR AGENCY

Worker's Compensation

ALEXSIS

 

 

 

BENEFIT

HOW PAYABLE

 

 

 

AMOUNT

 

 

 

 

 

 

 

 

 

 

FROM

 

 

THRU

 

 

 

 

 

 

 

 

 

$

 

 

_____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AUTHORIZATION

The above answers are true and complete according to the best of my knowledge and belief. I authorize any employer, insurance company, medical prepayment plan, service organization, physician, practioner or other person; any hospital including the Veterans Administration, or other institution to release to or obtain from the US Army Nonapprop Benefits Branch, any medical or benefit payment information that may be required to establish the validity of this claim, said company, person or organization, to disclose any personal or claim information required for medical case study or review. A photostat of this authorization shall be as valid as the original.

EMPLOYEE'S SIGNATURE______________________________

DATE

________________________

YOU MUST NOTIFY THE EMPLOYEE BENEFITS BRANCH PROMPTLY IF:

a.Your medical condition improves so that you would be able to work, even though you have not yet returned to wo

b.You go to work whether as an employee or as a self-employed person.

EBB Form 766-R (APR 2000)

Page 3 of 5

ATTENDING PHYSICIAN'S STATEMENT

REPLY TO:

US ARMY NAF EMPLOYEE BENEFITS BRANCH P.O. BOX 107

ARLINGTON, VA 22210-0107

PATIENT'S NAME

POLICYHOLDER NAME

DATE OF BIRTH_

CONTROL NUMBER: GAC 3730

The purpose of this report is to assist us in making a disability determination. In filing out this report please include insufficient details of history, physical and diagnostic findings, clinical course, therapy and response to enable us to make this determination. After signing this form, return it to the address noted above.

1. HISTORY

(a) Patient's Age.........................................

(b) When did symptoms first appear or accident happen

(c) Date patient ceased work because of disability........

(d) Has patient ever had same or similar condition?......

if "Yes" state when and describe......................

2.DIAGNOSIS (including any complications)

(a)Subjective symptoms.................................

(b) Objective findings..................................

(including current signs, laboratory data & X-ray results)

3.DATES OF TREATMENT

(a) Date of first visit..................................

(b) Date of last visit..................................

(c) Frequency...........................................

4. NATURE OF TREATMENT (Including Surgery, if any)

5.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROGRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a) Check one

Recovered

 

 

 

 

 

Improved

 

 

Unchanges

 

Retrogressed

 

 

 

 

 

(b)

Is patient

Ambulatory?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bed confined?

 

 

 

 

 

 

 

 

 

 

 

 

 

(c)

If hospital confined

Name of hospital

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Confined from

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

through

 

 

 

 

 

 

6. PHYSICAL IMPAIRMENT (AS IT RELATES TO EMPLOYMENT)

Class 1 - No limitation of functional capacity; capable of heavy physical activity. No restrictions. (0-10%) Class 2 - Slight limitation of functional capapcity; capable of light manual activity. (15-30%)

Class 3 - Moderate limitation of functional capacity; capable of clerical/administrative (sedentary) activity (35-55%) Class 4 - Marked limitation. (60-70%)

Class 5 - Severe limitation of functional capacity; incapable of minimal (sedentary) activity. (75-100%) Remarks:

EBB Form 766-R(APR 2000)

PAGE 4 OF 5

5. COMPETENCY

Is the patient competent to endorse checks and direct the use of the proceeds thereof?

6. PROGNOSIS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a) Do you expect a fundamental or

No

 

 

 

 

Yes-Improvement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

marked change in the future?

 

 

 

 

 

 

Yes-Deterioration

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HIS JOB

 

 

OTHER WORK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b) if improved, will patient recover

No

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

sufficiently to perform duties of

Yes

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3-6 mos

 

6-12 mos

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

over l yr

 

 

3-6 mos

6-12 mos

over l yr

 

 

 

 

 

 

 

 

 

(c) If no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

improvement expected, please explain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. REHABILITATION

HIS JOB

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER WORK

 

 

 

 

(a) Is patient a suitable candidate for trial

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

employment or job training?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

(b) If yes, when could he commence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

trial employment?

 

 

 

 

 

 

full time

 

part-time

 

 

 

full time

 

part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

mos. day year

 

 

 

 

 

 

 

 

 

mos. day year

 

 

 

 

 

 

 

 

 

(c) If no, please explain_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. REMARKS

 

Date

Name (Attending Physician) Print

 

 

 

Degree

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

City or Town

State or Province

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EBB Form 766-R (APR 2000)

Page 5 of 5

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How to complete 766 nonappropriated disability application part 1

2. Just after completing the last section, head on to the next step and fill in all required details in all these blanks - DID YOUR USUAL JOB INVOLVE A THE, PLEASE EXPLAIN ALL YES ANSWERS, DESCRIBE THE KIND AND AMOUNT OF, LIFTING AND CARRYING DESCRIBE WHAT, HOW DOES YOUR ILLNESS OR INJURY, a LIST ANY SKILLS WHICH YOU MAY, and b LIST LAST YEAR OF SCHOOL.

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TYPE OF TREATMENT RECEIVED, DATE OF LAST VISIT, and LIST THE NAME ADDRESS AND inside 766 nonappropriated disability application

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