Va Form 21 0960G 6 PDF Details

The VA 21 0960G-6 form, serving as a Peritoneal Adhesions Disability Benefits Questionnaire, is a crucial document for veterans seeking to prove the extent and severity of their peritoneal adhesions as part of their claim for disability benefits from the Department of Veterans Affairs (VA). This detailed questionnaire aims to capture comprehensive information about the veteran’s diagnosis, medical history, current health status, and the impact of peritoneal adhesions on their daily life and ability to work. Physicians are required to provide accurate and up-to-date medical information, including specific diagnoses related to peritoneal adhesions, a history of the condition including its onset, course, and any operative or traumatic causes, and details concerning the severity of the condition via specific symptoms and their impact on everyday activities. Moreover, the form mandates disclosure of any treatment plans including continuous medication, thereby offering a holistic view of the veteran's health with respect to the peritoneal adhesions. The VA emphasizes that the form must be filled out meticulously, as the information provided is critical to the VA's decision-making process regarding the veteran's eligibility for disability benefits. It also notes the privacy act notice and the importance of the respondent burden, reminding veterans and physicians alike that this effort is key to ensuring that veterans receive the benefits they are entitled to.

QuestionAnswer
Form NameVa Form 21 0960G 6
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdisabilityexams, 21-0960G-6, 21-0960F-1, va form 21 526b compensation

Form Preview Example

OMB Control No. 2900-0778

Respondent Burden: 15 minutes

PERITONEAL ADHESIONS 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 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 consider the information you provide on this questionnaire as part of their evaluation in processing the veteran's claim.

SECTION I - DIAGNOSIS

1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A PERITONEAL ADHESION?

YES

NO (If "Yes," complete Item 1B)

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO PERITONEAL ADHESIONS:

Diagnosis # 1 -

ICD code -

Date of diagnosis -

 

 

 

Diagnosis # 2 -

ICD code -

Date of diagnosis -

 

 

 

Diagnosis # 3 -

ICD code -

Date of diagnosis -

 

 

 

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO PERITONEAL ADHESIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY

2A. DESCRIBE THE HISTORY (including cause, onset and course) OF THE VETERAN'S PERITONEAL ADHESIONS (brief summary):

2B. DOES THE VETERAN HAVE A HISTORY OF OPERATIVE, TRAUMATIC OR INFECTIOUS (INTRAABDOMINAL) PROCESS?

YES NO

IF YES, INDICATE ORGAN(S) AFFECTED (check all that apply):

 

STOMACH

 

GALL BLADDER

 

LIVER

 

SMALL INTESTINES

 

LARGE INTESTINES

OTHER:

2C. HAS THE VETERAN HAD SEVERE PERITONITIS, RUPTURED APPENDIX, PERFORATED ULCER OR OPERATION WITH DRAINAGE?

YES NO

2D. DOES THE VETERAN HAVE A CURRENT DIAGNOSIS OF PERITONEAL ADHESIONS?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF YES, INDICATE ORGAN(S) AFFECTED (check all that apply):

 

 

 

 

 

 

 

STOMACH

 

 

GALL BLADDER

 

 

LIVER

 

 

SMALL INTESTINES

 

 

LARGE INTESTINES

 

OTHER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2E. DOES THE VETERAN HAVE ANY SIGNS AND/OR SYMPTOMS DUE TO PERITONEAL ADHESIONS?

 

 

 

 

 

 

 

 

 

 

 

IF YES, INDICATE SIGNS AND SYMPTOMS: (check all that apply)

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

DELAYED MOTILITY OF BARIUM MEAL (on X-ray)

 

 

NAUSEA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PARTIAL OR COMPLETE BOWEL OBSTRUCTION

 

 

VOMITING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REFLEX DISTURBANCES

 

 

 

 

 

ABDOMINAL DISTENTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAIN

 

 

 

 

 

 

 

 

 

 

CONSTIPATION (perhaps alternating with diarrhea)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

LIST MEDICATIONS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION III - SEVERITY OF MANIFESTATIONS OF PERITONEAL ADHESIONS

NOTE - Indicate level of severity of signs and/or symptoms, if present: (Check all that apply in each level)

3A. LEVEL IV

 

 

 

 

 

SEVERE

 

DEFINITE PARTIAL

 

 

 

 

 

 

 

 

 

OBSTRUCTION SHOWN BY X-RAY

 

PROLONGED EPISODES OF SEVERE COLIC DISTENSION

FREQUENT EPISODES OF SEVERE

 

FREQUENT EPISODES

 

FREQUENT EPISODES

COLIC DISTENSION

 

OF SEVERE NAUSEA

 

OF SEVERE VOMITING

PROLONGED EPISODES OF SEVERE NAUSEA PROLONGED EPISODES OF SEVERE VOMITING

3B. LEVEL III

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MODERATELY SEVERE

 

PARTIAL OBSTRUCTION MANIFESTED BY

 

 

LESS FREQUENT

 

 

LESS PROLONGED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DELAYED MOTILITY OF BARIUM MEAL

 

 

EPISODES OF PAIN

 

 

EPISODES OF PAIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3C. LEVEL II

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MODERATE

 

 

PULLING PAIN ON ATTEMPTING

 

OCCASIONAL

 

OCCASIONAL

 

 

OCCASIONAL EPISODES

 

ABDOMINAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WORK OR AGGRAVATED BY

 

 

EPISODES

 

EPISODES

 

 

OF CONSTIPATION

 

DISTENSION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOVEMENTS OF THE BODY

 

 

OF COLIC PAIN

OF NAUSEA

(Perhaps alternating with diarrhea)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3D. LEVEL I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MILD, DESCRIBE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VA FORM

21-0960G-6

 

 

SUPERSEDES VA FORM 21-0960G-6, FEB 2011,

 

 

 

 

 

 

 

OCT 2012

 

 

WHICH WILL NOT BE USED.

 

 

 

 

 

 

 

 

Page 1

SECTION IV - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS

4A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN SECTION 1, DIAGNOSIS?

YES

NO

IF YES, ARE ANY OF THE SCARS PAINFUL OR UNSTABLE, OR IS THE TOTAL AREA OF ALL RELATED SCARS GREATER THAN OR EQUAL TO 39 SQUARE cm (6 square inches)?

YES

NO (If "Yes," also complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)

4B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY CONDITIONS LISTED IN SECTION 1, DIAGNOSIS?

YES

NO (If "Yes," describe - brief summary):

SECTION V - DIAGNOSTIC TESTING

5. HAS THE VETERAN HAD LABORATORY OR OTHER DIAGNOSTIC STUDIES PERFORMED AND ARE THE RESULTS AVAILABLE?

YES

NO (If "Yes," provide type of test or procedure, date and results - brief summary):

SECTION VI - FUNCTIONAL IMPACT

6.BASED ON YOUR EXAMINATION AND/OR THE VETERAN'S HISTORY, DOES THE VETERAN'S PERITONEAL ADHESION(S) IMPACT HIS OR HER ABILITY TO WORK?

YES

NO (If "Yes," describe the impact of each of the veteran's peritoneal adhesions, providing one or more examples)

SECTION VII - REMARKS

7. REMARKS (If any)

SECTION VIII - 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 AND FAX NUMBER

8E. PHYSICIAN'S MEDICAL LICENSE NUMBER

8F. PHYSICIAN'S ADDRESS

NOTE - VA may request additional medical information, including additional examinations, 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.benefits.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 voluntary. 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 21-0960G-6, OCT 2012

Page 2

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