Va Form 21 0960A 1 PDF Details

In the realm of veteran affairs, navigating the intricate procedures necessary to claim disability benefits can often seem daunting. Of particular note is the VA Form 21-0960A-1, a critical document designed specifically for veterans suffering from Ischemic Heart Disease (IHD). Given its significance, it's paramount for veterans and their healthcare providers to understand the gravity and purpose of this form. Essentially, it serves as a detailed questionnaire that healthcare professionals complete to document the severity and implications of a veteran's IHD on their functional capacity and daily life. The form meticulously covers various aspects, including diagnosis codes, medical history regarding the heart condition, treatments, and any impact the condition might have on the veteran's ability to work. Such comprehensiveness ensures that the Department of Veterans Affairs (VA) is furnished with all necessary information to accurately process a veteran's disability claim. Despite the promise of no financial reimbursement for the efforts to complete and submit this form, it stands as a testament to the government's commitment to understanding and addressing the unique health challenges faced by those who have served. It underscores the procedural necessity for veterans to accurately articulate the extent of their heart disease, supported by medical evidence, to secure the benefits tailored to their sacrifice and service.

QuestionAnswer
Form NameVa Form 21 0960A 1
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesx-ray, SSN, LVEF, va form 21 0960a 1

Form Preview Example

OMB Approved No. 2900-0749

Respondent Burden: 15 minutes

ISCHEMIC HEART DISEASE (IHD) 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 ON REVERSE BEFORE COMPLETING FORM.

NAME OF PATIENT/VETERAN

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 use the information you provide on this questionnaire to process the Veteran's claim.

SECTION I - DIAGNOSIS

Note: IHD includes, but is not limited to, acute, sub-acute and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina. IHD does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease.

IHD encompasses any atherosclerotic heart disease resulting in clinically significant ischemia or requiring coronary revascularization.

1A. DOES THE VETERAN HAVE ISCHEMIC HEART DISEASE (IHD)?

 

 

YES

 

NO

 

 

 

 

 

Note: Provide only diagnoses that pertain to IHD

 

 

 

 

 

1B. DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

 

 

 

1C. DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

 

 

 

1D. DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

 

 

 

 

 

 

 

1E. IF ADDITIONAL DIAGNOSES THAT PERTAIN TO IHD, LIST USING ABOVE FORMAT

SECTION II - MEDICAL HISTORY

2A. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?

 

YES

 

NO

2B. LIST MEDICATIONS PRESCRIBED FOR IHD-RELATED CONDITIONS:

2C. IS THERE A HISTORY OF: (Check all that apply and provide treatment facility and treatment date)

 

 

 

CONDITION

 

 

 

 

YES (Check)

NO (Check)

TREATMENT FACILITY

 

DATE OF TREATMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERCUTANEOUS CORONARY INTERVENTION (PCI)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MYOCARDIAL INFARCTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CORONARY BYPASS SURGERY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEART TRANSPLANT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If "Yes," is it as likely as not that the veteran's heart

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO)

 

 

 

 

 

 

 

 

 

 

 

 

transplant is due to IHD?

 

 

 

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IMPLANTED CARDIAC PACEMAKER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If "Yes," is it as likely as not that the veteran's

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

pacemaker is due to IHD?

 

 

YES

 

 

NO)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IMPLANTED AUTOMATIC IMPLANTABLE

 

 

 

 

 

 

 

 

 

 

 

 

CARDIOVERTER DEFIBRILLATOR (AICD) (If

"Yes,"

 

 

 

 

 

 

 

 

 

 

is it as likely as not that the veteran's AICD is due to

 

 

 

 

 

 

 

 

 

 

IHD?

 

YES

 

NO)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION III - CONGESTIVE HEART FAILURE (CHF)

 

 

 

 

3A. DOES THE VETERAN HAVE CHF?

 

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3B. IS THE VETERAN'S CHF CHRONIC?

 

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

3C. IF THE VETERAN'S CHF IS NOT CHRONIC, HAS THE VETERAN HAD MORE THAN ONE EPISODE OF ACUTE CHF IN THE PAST YEAR?

 

YES

 

NO

 

 

If "Yes," provide name of treatment facility:

Date of most recent episode of CHF:

SECTION IV - CARDIAC FUNCTIONAL ASSESSMENT

4A. HAS A DIAGNOSTIC EXERCISE TEST BEEN CONDUCTED?

 

YES

 

NO

If "Yes," provide level of METS the veteran can perform as shown by diagnostic exercise testing:

Date of most recent test:

VA FORM 21-0960A-1

MAY 2010

4B. IF EXERCISE METs TESTING WAS NOT COMPLETED BECAUSE IT IS NOT REQUIRED AS PART OF THE VETERAN'S TREATMENT PLAN, COMPLETE THE FOLLOWING METs TEST BASED ON THE VETERAN'S RESPONSES:

Lowest level of activity at which veteran reports symptoms (Check all symptoms that apply)

 

DYSPNEA

 

FATIGUE

 

ANGINA

 

DIZZINESS

 

SYNCOPE

This METs Level has been found to be consistent with activities such as:

1-3 METS (This METs level has been found to be consistent with activities such as eating, dressing, taking a shower, slow walking (2 mph) for 1-2 blocks)

>3-5 METS (This METs level has been found to be consistent with activities such as light yard work (weeding), mowing lawn (power mower), brisk walking (4 mph)

>5-7 METS (This METs level has been found to be consistent with activities such as golfing (without cart), mowing lawn (push mower), heavy yard work (digging)

>7-10 METS (This METs level has been found to be consistent with activities such climbing stairs quickly, moderate bicycling, sawing wood, jogging (6 mph)

Veteran denies experiencing above symptoms with any level of physical activity

SECTION V - DIAGNOSTIC TESTING

NOTE: Determination of cardiac hypertrophy/dilatation is required; the suggested order of testing for cardiac hypertrophy/dilatation is EKG, then chest x-ray (PA and lateral), then echocardiogram. Echocardiogram is only necessary if the other two tests are negative. A limited echocardiogram, if available, is appropriate to determine if cardiac hypertrophy/dilatation is present by measuring only left ventricular dimension, wall thickness and ejection fraction.

5A. IS THERE EVIDENCE OF CARDIAC HYPERTROPHY OR DILATATION?

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5B. DIAGNOSTIC TEST AND DATE GIVEN (Provide most recent test only)

 

 

 

 

 

 

 

 

 

EKG - Date of EKG:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHEST X-RAY - Date of chest x-ray:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ECHOCARDIOGRAM - Date of echocardiogram:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER STUDY (Specify):

 

 

 

(Date):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5C. LEFT VENTRICULAR EJECTION FRACTION (LVEF), IF KNOWN:

 

%

DATE OF TEST:

 

 

(If LVEF testing is not of record, but available medical information sufficiently reflects the severity of the veteran's cardiovascular condition, LVEF testing is not required)

SECTION VI - FUNCTIONAL IMPACT AND REMARKS

6. DOES THE VETERAN'S IHD IMPACT THE VETERAN'S ABILITY TO WORK?

 

YES

 

NO (If "Yes," describe impact, providing one or more examples)

7. REMARKS (If any)

SECTION VII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.

8A. PHYSICIAN'S SIGNATURE

8B. PHYSICIAN'S PRINTED NAME

8C. DATE SIGNED

8D. PHYSICIAN'S PHONE NUMBER

8E. PHYSICIAN'S MEDICAL LICENSE NUMBER

8F. PHYSICIAN'S ADDRESS

NOTE - VA may obtain additional medical information, including an examination, 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.vba.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 required to obtain or retain benefits. 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.

VA FORM MAY 2010, 21-0960A-1

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1. Fill out the SSN with a group of essential blanks. Note all of the necessary information and make sure nothing is forgotten!

Completing section 1 of CHF

2. Given that the previous array of fields is done, you're ready to insert the essential particulars in B LIST MEDICATIONS PRESCRIBED FOR, C IS THERE A HISTORY OF Check all, CONDITION, YES Check, NO Check, TREATMENT FACILITY, DATE OF TREATMENT, PERCUTANEOUS CORONARY INTERVENTION, MYOCARDIAL INFARCTION, CORONARY BYPASS SURGERY, HEART TRANSPLANT, If Yes is it as likely as not that, transplant is due to IHD, YES, and IMPLANTED CARDIAC PACEMAKER If Yes allowing you to proceed to the 3rd stage.

CHF writing process explained (portion 2)

It is possible to make errors while completing your TREATMENT FACILITY, for that reason you'll want to go through it again before you'll submit it.

3. In this particular step, take a look at A HAS A DIAGNOSTIC EXERCISE TEST, YES, If Yes provide level of METS the, Date of most recent test, and VA FORM MAY A. Every one of these need to be taken care of with greatest accuracy.

The way to prepare CHF step 3

4. Filling in Lowest level of activity at which, DYSPNEA, FATIGUE, ANGINA, DIZZINESS, SYNCOPE, This METs Level has been found to, METs This METs level has been, METs This METs level has been, METs This METs level has been, METs This METs level has been, Veteran denies experiencing above, NOTE Determination of cardiac, SECTION V DIAGNOSTIC TESTING, and A IS THERE EVIDENCE OF CARDIAC is vital in this fourth step - you should definitely invest some time and take a close look at each and every field!

Filling in segment 4 of CHF

5. The very last section to conclude this form is pivotal. You'll want to fill out the appropriate blank fields, for example DOES THE VETERANS IHD IMPACT THE, YES, NO If Yes describe impact, REMARKS If any, CERTIFICATION To the best of my, SECTION VII PHYSICIANS, A PHYSICIANS SIGNATURE, B PHYSICIANS PRINTED NAME, C DATE SIGNED, D PHYSICIANS PHONE NUMBER, E PHYSICIANS MEDICAL LICENSE NUMBER, F PHYSICIANS ADDRESS, NOTE VA may obtain additional, IMPORTANT Physician please fax, and VA Regional Office FAX No, before using the pdf. Neglecting to do so may end up in an incomplete and potentially nonvalid document!

Tips on how to complete CHF stage 5

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