Va Form 21 0819 PDF Details

In the web of administrative and procedurial documents that sculpt the landscape of veteran affairs and service member benefits, the VA Form 21-0819 stands as a pivotal bridge between the Department of Defense (DoD) and the Department of Veterans Affairs (VA), facilitating the transition for service members undergoing the Integrated Disability Evaluation System (IDES). This form, crafted within a structure approved by the Office of Management and Budget (OMB No. 2900-0704) with a prescribed respondent burden of 15 minutes, serves as a conduit for military treatment facilities to refer service members to the IDES. It delineates a meticulously structured process designed to ensure that crucial details, ranging from the service member's personal information to the specifics of their medical conditions and the assigned Military Treatment Facility, are accurately captured. Furthermore, it underscores the significance of a comprehensive transfer of Service Treatment Records (STRs) to the VA, ensuring that decisions regarding fitness for duty and potential entitlements to compensation benefits are made based on complete and current information. The form also outlines the mechanisms for addressing missing STRs, thereby ensuring a seamless continuation of care and benefits determination. VA FORM 21-0819, nuanced in its construction, embodies a critical step within the IDES by providing a standardized method for referral, promising a path towards a structured and supported transition for service members navigating the complexities of disability evaluation.

QuestionAnswer
Form NameVa Form 21 0819
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform 0819, fillable joint dod fill, va 2900 0704, form 21 0819

Form Preview Example

OMB Approved No. 2900-0704

Respondent Burden: 15 minutes

Expiration Date: 7/31/2021

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE -

FOR VA USE ONLY)

DoD REFERRAL TO INTEGRATED DISABILITY EVALUATION SYSTEM (IDES)

This form is to be completed by the Military Treatment Facility that is referring the

Service member to the Integrated Disability Evaluation System (IDES).

SECTION I - SERVICE MEMBER'S INFORMATION

1.SERVICE MEMBER'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

 

 

 

 

 

 

 

3. VTA CASE ID

 

 

 

 

 

 

 

4. DATE OF BIRTH (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. GENDER

6. TELEPHONE NUMBER

(Include Area Code)

 

 

 

7. E-MAIL ADDRESS (Optional)

 

 

 

 

 

 

 

 

 

 

MALE FEMALE

8.CURRENT MAILING ADDRESS (Number and Street or rural route, P.O. Box, City, State, ZIP Code Country)

No. & Street

Apt./Unit Number

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State/Province

 

 

 

 

 

Country

 

 

 

 

 

 

 

ZIP Code/Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. COMPONENT

 

 

 

 

 

 

 

 

 

 

 

 

 

10. DUTY STATUS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. GRADE

 

 

ACTIVE

 

GUARD

 

 

RESERVE

 

 

 

 

 

 

ON ACTIVE DUTY

 

 

NOT ON ACTIVE DUTY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. UNIT ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION II - MEDICAL EVALUATION BOARD (MEB) INFORMATION

13. ASSIGNED PHYSICAL EVALUATION BOARD LIAISON OFFICER (PEBLO) (First, Middle Initial, Last)

14.TELEPHONE NUMBER (Include Area Code)

15. DATE OF REFERRAL TO MEB (MM/DD/YYYY)

Month

 

 

 

Day

 

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16.REFERRING MILITARY TREATMENT FACILITY

17.MEDICAL CONDITIONS TO BE CONSIDERED AS THE BASIS OF FITNESS FOR DUTY DETERMINATIONS

(List only conditions referred by physician; continue on page 2 if necessary.)

1.

2.

3.

4.

5.

18. PREPARED BY

6.

7.

8.

9.

10.

19. DATE SIGNED (MM/DD/YYYY)

VA FORM

21-0819

SUPERSEDES VA FORM 21-0819, JUL 2016,

JUL 2018

WHICH WILL NOT BE USED.

SOCIAL SECURITY NUMBER

SECTION III - STATEMENT OF COMPLETE AND CURRENT STR

20.All available military Service Treatment Records (STR) for the Service member identified above are forwarded to the VA Military Services Coordinator (MSC) as directed by DoDI 1332.18-Volume II (Disability Evaluation System (DES) Manual; Integrated Disability Evaluation System (IDES)), Appendix 4 to Enclosure 4.

The STR provided with this form contains a complete history of documented healthcare, including entrance and applicable exit physicals, and healthcare documented from the electronic health record (CHCS, AHLTA, or equivalent) systems. TRICARE network, and dental system of record for those cases referred for a dental condition

WITHOUT known exception (skip blocks 21 and 22) WITH exception (complete blocks 21 and 22)

21.DESCRIPTION OF MISSING STR (If any)

22.ACTION(S) TAKEN TO OBTAIN MISSING STR (Provide detailed description of all efforts and outcomes, to include the date of all activity; continue below if necessary.)

23. PEBLO SIGNATURE

24.DATE SIGNED (MM/DD/YYYY)

SECTION IV - REMARKS

The form will be used to determine allowance to compensation benefits (38 U.S.C. 5101). The responses you submit are considered

confidential (38 U.S.C. 5701). VA may disclose the information that you provide, including Social Security numbers, outside VA if the disclosure is authorized under

the Privacy Act, including the routine uses identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education, and Vocational Rehabilitation and

Employment Records - VA, published in the Federal Register. The requested information is considered relevant and necessary to determine maximum benefits under the

law. Information submitted is subject to verification through computer matching programs with other agencies. VA may make a "routine use" disclosure for: 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. Your obligation to respond is required in order to obtain or retain benefits. Information that you furnish may be utilized in computer matching programs

with other Federal or state agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by

virtue of your participation in any benefit program administered by the Department of Veterans Affairs. Social Security information: You are required to provide the

Social Security number requested under 38 U.S.C. 5101(c)(1). VA may disclose Social Security numbers as authorized under the Privacy Act, and, specifically may

disclose them for purposes stated above.

 

We need this information to determine your eligibility for compensation. 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 this 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 acollection of information if this number is not

displayed. Valid OMB control numbers can be located on the OMB Internet Page at

. If desired, you can call 1-800-827-1000 to

get information on where to send comments or suggestions about this form.

 

VA FORM 21-0819, JUL 2018

Page 2

Va Form 21 0819 isn’t the one you’re looking for?

Related Documents