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OMB Approved No. 2900-0776 Respondent Burden: 45 minutes EYE CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE IMPORTANT: THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES

How to fill out 21 0960m 12 form

How to fill out 21 0960m 12 form:

1. Begin by reading the instructions provided with the form carefully. Familiarize yourself with the purpose of the form and the information required.
2. Gather all the necessary documents and information needed to complete the form accurately. This may include medical records, test results, and personal information.
3. Start by providing your personal details such as your name, contact information, and social security number in the designated fields.
4. Proceed to section A of the form, which pertains to the veteran's identifying information. Fill in your date of birth, branch of service, and dates of service as required.
5. In section B, provide details about the condition being claimed. Include the diagnosis, date of diagnosis, and the name and address of the medical facility where you received treatment.
6. If you are claiming secondary conditions, provide relevant details in section C, including the relationship to the primary condition and the date it began affecting you.
7. In section D, list all the symptoms related to the claimed condition. Be thorough and specific in describing the frequency and severity of each symptom.
8. If there are any additional factors that contribute to or affect the claimed condition, such as medications or treatments, disclose them in section E.
9. Section F requires information about your work history, including your current employment status and any limitations or restrictions caused by the claimed condition.
10. If you received or are receiving any benefits or compensation for the claimed condition, indicate them in section G.
11. Finally, sign and date the form in the appropriate spaces provided. Ensure that you have provided accurate and complete information before submitting it.

Who needs 21 0960m 12 form:

1. Veterans who are seeking disability benefits or compensation for a service-connected condition.
2. Individuals who have been diagnosed with a medical condition related to their military service and want to apply for disability benefits.
3. Those who need to provide additional details or update their existing disability claim with new medical information.

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