Sglv 8600 Form – Fill Out and Use This PDF

The service member, guardian, power of attorney or military trustee MUST fill

in member’s Social Security number at the top of each page.

Important Note: Contact information must be completed. Incomplete information

Address of Record (number and street)

will delay payment of your claim.

E-mail Address

Third Party Authorization

First Name

(Optional) I authorize the following person to speak with OSGLI or the Branch of Service about my claim (this can be a spouse, parent, friend or another person who is helping you with your claim).

2Guardian, Power of Attorney or Military Trustee Information

Important Note: Please include copies of the letters of guardianship, conservatorship, or Power of Attorney, etc. with this form. Failure to include this documentation will delay processing of the claim.

Complete this section ONLY if a guardian, power of attorney or military trustee will receive payment on behalf of the member.

3Traumatic Injury Information

Injuries that Qualify for TSGLI Payment

In order to qualify for the TSGLI benefit, you must have experienced a traumatic event that resulted in a traumatic injury that is listed as a qualifying loss on the TSGLI Schedule of Losses.

Definitions:

Traumatic Event — A traumatic event is the application of external force, violence, chemical, biological, or radiological weapons, accidental ingestion of a contaminated substance, or exposure to the elements that causes damage to your body.

Traumatic Injury — A traumatic injury is the physical damage to your body that resulted from a traumatic event (illness or disease is not covered).

Qualifying Loss — A qualifying loss is a traumatic injury that is listed on the TSGLI Schedule of Losses. You may view the complete Schedule of Losses at http://www.benefits.va.gov/insurance/tsgli_schedule_Schedule.asp.

If you answered yes…

to any of the questions above, you are not eligible for a TSGLI payment and should not file a claim.

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

Tell us about your traumatic Injury

1.Were you covered under Servicemembers Group Life Insurance (SGLI) at the time of the injury?

Yes

No

4Payment Options

Please choose one of the three payment options by checking the appropriate box and filling in the requested information.

Please choose one of the three payment options below:

Payment Option 1 - Prudential’s Alliance Account®

Complete the mailing address below (street address only, no PO boxes.)

Payment Option 1

–Prudential’s Alliance Account An interest-bearing account will be established in the name of the member, who can access the money using the draft book. A guardian, power of attorney,

or military trustee may sign Alliance Account® drafts on behalf of the member if proof of appointment is submitted with the claim.

Payment Option 2

–Electronic Funds Transfer This option can be selected by member or, if applicable, the guardian, power of attorney or military trustee. Payment will be made to the service member’s bank account.

Payment Option 3 – Check

A check will be issued to the service member, guardian, power of attorney or military trustee on behalf of the service member.

Payment Option 2 - Electronic Funds Transfer (EFT)

To have the payment made by EFT, fill in your banking information below.

Payment Option 3 - Check

Important: If you are a guardian, power of attorney or military trustee you must complete the information below when requesting a check.

5Financial Counseling

VA sponsors financial counseling for TSGLI recipients.

To receive this counseling, check the box below.

I would like to receive financial counseling with my TSGLI benefit.

You should get financial counseling as soon as possible after receiving your insurance money and before making any major financial decisions. For more information on this benefit, visit http://www.benefits.va.gov/insurance/bfcs.asp.

Signature of service member, guardian, power of attorney or military trustee Date Signed (MM DD YYYY)

WARNING: Any intentional false statement in this claim or willful misrepresentation relative thereto is subject to punishment by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001)

Description of Authority to act on behalf of the member (Guardian, POA, etc.)

7Authorization for Release of Information to Branch of Service and Office of Servicemembers’ Group Life Insurance

The member, guardian, power of attorney, or military trustee must complete and sign this section.

Member must complete and sign the HIPAA release below:

I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, medical examiner or other health care provider that has provided treatment, payment or services pertaining to:

Date of Birth (MM DD YYYY)

or on my behalf (“My Providers”) to disclose my entire medical record for me or my dependents and any other health information concerning me to the Branch of Service and Office of Servicemembers’ Group Life Insurance (OSGLI) and its agents, employees, and representatives. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco, but excludes psychotherapy notes. OSGLI is an administrative unit created by Prudential to administer the Servicemembers’ Group Life Insurance Program. OSGLI administers the TSGLI program on behalf of the Department of Veterans Affairs.

Failure to complete this section will delay payment of claim

This authorization is intended to comply with the HIPAA Privacy Rule.

I authorize all non-health organizations, any insurance company, employer, or other person or institutions to provide any information, data or records relating to credit, financial, earnings, travel, activities or employment history to OSGLI.

Unless limits* are shown below, this form pertains to all of the records listed above.

By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization and I instruct My Providers to release and disclose my entire medical record without restriction.

This information is to be disclosed under this Authorization so that my Branch of Service and OSGLI may: 1) administer claims and determine or fulfill responsibility for coverage and provision of benefits, 2) administer coverage, and 3) conduct other legally permissible activities that relate to any coverage I have applied for with OSGLI.

This authorization shall remain in force for 24 months following the date of my signature below, while the coverage is in force, except to the extent that state law imposes a shorter duration. A copy of this authorization is as valid as the original. I understand that I have the right to revoke this authorization in writing, at any time, by sending a written request for revocation to OSGLI at:

80 Livingston Avenue, Roseland, NJ 07068. I understand that a revocation is not effective to the extent that any of My Providers has relied on this Authorization or to the extent that OSGLI has a legal right to contest a claim under an insurance policy or to contest the policy itself. I understand that any information that is disclosed pursuant to this authorization may be redisclosed and no longer covered by federal rules governing privacy and confidentiality of health information.

I understand that if I refuse to sign this authorization to release my complete medical record, OSGLI may not be able to process my claim for benefits and may not be able to make any benefit payments. I understand that I have the right to request and receive a copy of this authorization.

Signature

The member, guardian, power of attorney or military trustee must sign here.

X

Signature of service member, guardian, power of attorney or military trustee

Date Signed (MM DD YYYY)

Description of Authority to act on behalf of the member (Guardian, POA, etc.)

Information

Date of Injury (MM DD YYYY)

If patient is deceased, please provide:

:

Cause of Death

A.M.

P. M.

2Qualifying Losses Suffered by Patient

Instructions: Please check the box next to each loss the patient has experienced and fill in any additional information requested. Omitted information, such as sight or hearing measurements, will delay processing of the claim.

Patient’s loss MUST meet the definition of loss given.

Inpatient hospitalization is defined as: “Being hospitalized as an inpatient for 15 consecutive days as the result of a traumatic injury”

Definition of a hospital – A hospital that is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on Accreditation of Healthcare Organizations. This includes Combat Support Hospitals, Air Force Theater Hospitals and Navy Hospital Ships.

Hospital does not include a nursing home. Neither does it include an institution, or part of one, which: (1) is used mainly as a place for convalescence, rest, nursing care or for the aged; or (2) furnishes mainly homelike or Custodial Care, or training in the routines of daily living; or (3) is for residential or domiciliary living; or (4) is mainly a school.

Reason for Inpatient Hospitalization – Please give the predominant reason the patient was hospitalized.

Longest Period of Inpatient Hospitalization – Please give the beginning and ending dates for the longest period of consecutive days the patient was hospitalized as an inpatient. The count of consecutive inpatient hospitalization days begins when the injured member is transported to the hospital (if applicable), includes the day of admission, continues through subsequent transfers from one hospital to another, and includes the day of discharge.

Name and location of hospital (if more than one hospital, list all)

Loss of Sight is defined as:

■■Visual acuity in at least one eye of 20/200 or less (worse) with corrective lenses OR,

■■Visual acuity in at least one eye of greater (better) than 20/200 with corrective lenses and a visual field of 20 degrees or less OR,

■■Anatomical loss of eye. Loss of sight must be expected to be permanent OR must have lasted at least 120 days

Visual Field (degrees)

Loss of Speech is defined as:

An organic loss of speech (lost the ability to express oneself, both by voice and by whisper, through normal organs for speech). If a member uses an artificial appliance, such as a voice box, to simulate speech, he/she is still considered to have suffered an organic loss of speech and is eligible for a TSGLI benefit.

25 Qualifying

Losses Suffered by Patient (cont’d)

Loss of hearing is defined as:

Average hearing threshold sensitivity for air conduction of at least 80 decibels. Hearing Acuity must be measured at 500 Hz, 1000 Hz and 2000 Hz to calculate the average hearing threshold. Loss of hearing must be clinically stable and unlikely to improve.

Loss of Hearing

Loss of hearing in left ear

Loss of hearing in right ear

Hearing Acuity

Average Hearing Acuity (measured without amplification device)

Date of onset

Left Ear

db

Right Ear

db

Note: Percentage may be measured using

the Rule of Nines or any other acceptable alternative.Percentage of body affected

Percentage of

%face affected

%

Coma is defined as:

Coma with brain injury measured at a Glasgow Coma Score of 8 or less that lasts for 15, 30, 60 or 90 consecutive days.

Number of days includes the date the coma began and the date the member recovered from the coma.

OR

Check here if coma is ongoing

Glasgow score at 15 days

Glasgow score at 30 days

Glasgow score at 60 days

Glasgow score at 90 days

Important:

Facial Reconstruction: If the patient is undergoing facial reconstruction, a surgeon MUST certify this section by checking the box, printing his/her name and signing on the appropriate line.

Facial Reconstruction is defined as:

Reconstructive surgery to correct traumatic avulsions of the face or jaw that cause discontinuity defects, specifically surgery to correct discontinuity loss of the following:

■■upper or lower jaw

■■50% or more of the cartilaginous nose

■■50% or more of the upper or lower lip

■■30% or more of the periorbital

■■tissue in 50% or more of any of the following facial subunits: forehead, temple, zygomatic, mandibular, infraorbital or chin.

Certification of Surgeon

Date of first surgery

Name of Surgeon

Facial Reconstruction

Upper or lower jaw

50% of cartilaginous nose

50% of upper lip

50% of lower lip

30% of left periorbital

30% of right periorbital

50% of left temple

50% of right temple

50% of left zygomatic

50% of right zygomatic

50% of left mandibular

50% of right mandibular

50% of left infraorbital

50% of right infraorbital

50% of chin

50% of forehead

X

Signature of Surgeon

Date Signed (MM DD YYYY)

SGLV 8600 Page 9

25 Qualifying

Losses Suffered by Patient (cont’d)

Amputation is: the severance or removal of a limb or genital organ or part of a limb or genital organ, including both severance due to a traumatic injury, or surgical removal that is required for the treatment of a traumatic injury.

Amputation of Fingers is defined as:

■■Amputation of four fingers on the same hand (not including the thumb) at or above the metacarpophalangeal joint OR,

■■Amputation of thumb at or above the metacarpophalangeal joint.

Above the metacarpophalangeal joint means closer to the body.

Amputation of 4 fingers/ left hand

Amputation of 4 fingers/ right hand

Amputation of left thumb

Amputation of right thumb

■■Amputation of all toes (including the big toe) on the

same foot at or above the metatarsophalangeal joint.

Above the ankle and above the metatarsophalangeal joint means closer to the body.

Amputation of right foot

Important:

Limb Salvage: If the patient is undergoing limb salvage, a surgeon MUST certify this

section by printing his/her name and signing on the appropriate line.

Submit operative report for each surgery.

Certification of Surgeon

I certify that the patient is undergoing limb salvage surgery as defined in the column to the right.

Name of Surgeon

Salvage of right arm

Salvage of right leg

Additional Comments

25 Qualifying

Losses Suffered by Patient (cont’d)

Paralysis is defined as:

Complete paralysis due to damage to the spinal cord or associated nerves, or to the brain. A limb is defined as an arm or a leg with all its parts. Paralysis must fall into one of the four categories listed below:

■■Quadriplegia - paralysis of all four limbs

■■Paraplegia - paralysis of both lower limbs

■■Hemiplegia - paralysis of the upper and lower limbs on one side of the body

■■Uniplegia - paralysis of one limb

Quadriplegia

Paraplegia

Hemiplegia

Uniplegia

Anatomical loss of one testicle is defined as:

The amputation of, or damage to, one testicle that requires testicular salvage, reconstructive surgery, or both.

Anatomical loss of both testicle(s) is defined as:

The amputation of, or damage to, both testicles that requires testicular salvage, reconstructive surgery, or both.

Permanent loss of use of both testicles is defined as:

Damage to both testicles resulting in the need for hormonal replacement therapy that is medically required and reasonably certain to continue throughout the lifetime of the member.

Anatomical loss of the vulva is defined as:

The complete or partial amputation of the vulva or damage to the vulva that requires reconstructive surgery.

Anatomical loss of the uterus is defined as:

The complete or partial amputation of the uterus or damage to the uterus that requires reconstructive surgery.

Anatomical loss of the vaginal canal is defined as:

The complete or partial amputation of the vaginal canal or damage to the vaginal canal that requires reconstructive surgery.

Permanent loss of use of the vulva is defined as:

Damage to the vulva that results in complete loss of the ability to perform sexual intercourse that is reasonably certain to continue throughout the lifetime of the member.

Permanent loss of use of the vaginal canal is defined as:

Damage to the vaginal canal that results in complete loss of the ability to perform sexual intercourse that is reasonably certain to continue throughout the lifetime of the member.

25 Qualifying

Losses Suffered by Patient (cont’d)