Va Form For Sleep Apnea PDF Details

The Va for Sleep Apnea form, under the control of the Office of Management and Budget (OMB Control No. 2900-0778), is a critical document for veterans seeking disability benefits due to sleep apnea. It outlines a comprehensive process for documenting the diagnosis, symptoms, and effects of sleep apnea on the veteran's life, with an estimated respondent burden of 15 minutes. This form warns that the Department of Veterans Affairs (VA) will not cover any costs incurred in its completion or submission. Information provided includes detailed sections on diagnosis, medical history, findings, signs and symptoms, other physical findings, diagnostic testing, the impact on the veteran's ability to work, and final remarks. Physicians play a pivotal role as their certification on the form's accuracy is crucial. Specifically, this form covers various types of sleep apnea, including obstructive, central, and mixed, and requires confirmation via a sleep study. Additionally, it explores the necessity of continuous medication or the use of breathing assistance devices like CPAP machines. The VA uses the information collected to determine entitlement to benefits, emphasizing the importance of accuracy in the form's completion and the potential requirement for additional medical information or examinations by the VA. Privacy considerations are noted, with assurances that information provided will be protected under the Privacy Act of 1974 and relevant VA regulations, underscoring the form's vital role in the process for veterans to claim sleep apnea-related disability benefits.

QuestionAnswer
Form NameVa Form For Sleep Apnea
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namessleep apnea dbq pdf, sleep apnea dbq example, sleep apnea dbq va, va dbq for sleep apnea

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OMB Control No. 2900-0778

Respondent Burden: 15 minutes

SLEEP APNEA 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 HAVE OR HAS HE OR SHE EVER HAD SLEEP APNEA?

 

YES

 

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

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO SLEEP APNEA AND CHECK DIAGNOSTIC TYPE:

OBSTRUCTIVE

ICD Code:

 

Date of diagnosis:

CENTRAL

ICD Code:

 

Date of diagnosis:

MIXED, COMPONENTS OF BOTH

ICD Code:

 

Date of diagnosis:

OTHER SLEEP DISORDER (specify):

ICD Code:

 

Date of diagnosis:

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO A DIAGNOSIS OF SLEEP APNEA, LIST USING ABOVE FORMAT:

NOTE - The diagnosis of sleep apnea must be confirmed by a sleep study, provide the sleep study results in Section V, Diagnostic Testing. If other respiratory condition is diagnosed, complete VA Form 21-0960L-1, Respiratory Conditions Disability Benefits Questionnaire and/or VA Form 21-0960C-6, Narcolepsy Disability Benefits Questionnaire in lieu of this one.

SECTION II - MEDICAL HISTORY

2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S SLEEP DISORDER CONDITION (brief summary):

2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF A SLEEP DISORDER CONDITION?

YES

NO (If "Yes," list only those medications required for the veteran's sleep disorder condition):

2C. DOES THE VETERAN REQUIRE THE USE OF A BREATHING ASSISTANCE DEVICE SUCH AS A CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) MACHINE?

YES

NO

SECTION III - FINDINGS, SIGNS AND SYMPTOMS

3. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO SLEEP APNEA?

YES

NO

(If, "Yes," check all that apply)

Persistent daytime hypersomnolence

Evidence of chronic respiratory failure with carbon dioxide retention

Cor pulmonale

Requires tracheostomy

Other, describe:

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 I, DIAGNOSIS?

YES

NO

(If "Yes," are any of the scars painful and/or unstable, or is the total area of all related scars greater than ot equal to 39 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 I, DIAGNOSIS?

YES

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

VA FORM

21-0960L-2

SUPERSEDES VA FORM 21-0960L-2, FEB 2011,

Page 1

OCT 2012

 

WHICH WILL NOT BE USED.

 

SECTION V - DIAGNOSTIC TESTING

NOTE - If diagnostic test results are in the medical record and reflect the veteran's current sleep apnea condition, repeat testing is not required.

5A. HAS A SLEEP STUDY BEEN PERFORMED?

YES NO

(If, "Yes," does the veteran have documented sleep disorder breathing?)

YES

NO

Date of sleep study:

Name of facility where sleep study performed, if known:

Results:

5B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?

 

YES

 

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

 

 

 

 

SECTION VI - FUNCTIONAL IMPACT

 

 

 

 

6. DOES THE VETERAN'S SLEEP APNEA IMPACT HIS OR HER ABILITY TO WORK?

 

 

YES

 

NO (If "Yes," describe impact of the veteran's sleep apnea, 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 obtain 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, 58VA21/22/28, 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 a 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 21-0960L-2, OCT 2012

Page 2

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The right way to fill out dbq sleep apnea part 1

2. Just after this part is filled out, go to enter the suitable details in these: B IS CONTINUOUS MEDICATION, YES, If Yes list only those medications, C DOES THE VETERAN REQUIRE THE USE, YES, DOES THE VETERAN CURRENTLY HAVE, SECTION III FINDINGS SIGNS AND, YES, If Yes check all that apply, Persistent daytime hypersomnolence, Evidence of chronic respiratory, Cor pulmonale, Requires tracheostomy, Other describe, and SECTION IV OTHER PERTINENT.

dbq sleep apnea conclusion process described (portion 2)

3. This 3rd section should be quite simple, CONDITIONS LISTED IN SECTION I, YES, If Yes describe brief summary, VA FORM OCT, SUPERSEDES VA FORM L FEB WHICH, and Page - all of these blanks needs to be filled out here.

VA FORM OCT, Page, and CONDITIONS LISTED IN SECTION I of dbq sleep apnea

It is easy to get it wrong when completing the VA FORM OCT, so you'll want to take another look before you decide to send it in.

4. Completing A HAS A SLEEP STUDY BEEN PERFORMED, YES, If Yes does the veteran have, YES, Date of sleep study, Name of facility where sleep study, Results, B ARE THERE ANY OTHER SIGNIFICANT, YES, If Yes provide type of test or, DOES THE VETERANS SLEEP APNEA, YES, If Yes describe impact of the, SECTION VI FUNCTIONAL IMPACT, and REMARKS If any is key in this next section - make sure to don't hurry and take a close look at each and every field!

dbq sleep apnea completion process clarified (part 4)

5. The form has to be completed by filling in this section. Here you can find a comprehensive list of fields that need correct details for your document usage to be complete: CERTIFICATION To the best of my, A PHYSICIANS SIGNATURE, B PHYSICIANS PRINTED NAME, C DATE SIGNED, D PHYSICIANS PHONE AND FAX NUMBER, E PHYSICIANS MEDICAL LICENSE NUMBER, F PHYSICIANS ADDRESS, NOTE VA may obtain additional, IMPORTANT Physician please fax, VA Regional Office FAX No, NOTE A list of VA Regional Office, PRIVACY ACT NOTICE VA will not, VA FORM L OCT, and Page.

PRIVACY ACT NOTICE VA will not, B PHYSICIANS PRINTED NAME, and E PHYSICIANS MEDICAL LICENSE NUMBER of dbq sleep apnea

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