Get the free VA Form 21-0960a-2(12-10) - Veterans Benefits Administration - US ... - vba va
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VA FORM. DEC 2014. 21-0960A-2. ARTERY AND VEIN CONDITIONS (VASCULAR ... VA reserves the right to confirm the authenticity of ALL DBQ#39’s completed ..... at www.benefits.va.gov/disabilityexams or
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How to fill out va form 21-0960a-212-10
How to fill out VA Form 21-0960A-212-10:
01
Start by entering the veteran's name and social security number in the appropriate fields at the top of the form.
02
In Section I, provide the contact information for the person completing the form, including their name, address, phone number, and relationship to the veteran.
03
In Section II, indicate the specific condition being claimed by checking the appropriate box(es) provided. Be sure to provide detailed information about the condition, including the date of diagnosis and any treatments or medications being received.
04
In Section III, list all the locations where the veteran has received treatment for the claimed condition, including the dates of treatment and the names of the healthcare facilities or providers.
05
If the veteran is receiving or has received treatment from the VA, indicate this in Section IV and provide the name of the VA medical facility where treatment was received.
06
In Section V, describe any events or exposures that may have caused or aggravated the claimed condition. Provide detailed information about the circumstances surrounding these events or exposures.
07
If applicable, provide any additional evidence or supporting documents in Section VI that are relevant to the claimed condition.
08
In Section VII, certify that the information provided on the form is true and accurate to the best of your knowledge.
09
Finally, date and sign the form at the bottom, and ensure that any other required signatures are obtained and provided.
Who needs VA Form 21-0960A-212-10?
01
Veterans who are seeking to claim disability benefits from the Department of Veterans Affairs (VA) for a specific medical condition will need to fill out VA Form 21-0960A-212-10.
02
This form is typically required when applying for service-connected disability compensation or pension benefits.
03
The form is used to gather information about the veteran's claimed condition, as well as any relevant medical treatment and supporting evidence.
04
It is important to note that specific eligibility criteria may apply, and veterans should consult with the VA or a qualified representative to determine if they need to fill out this form for their particular situation.
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