VA 21-0781a 2014 free printable template

And Consent to Release Information to the Department of Veterans Affairs (VA), for each provider. ... SUPERSEDES VA FORM 21-0781A, JUN 2012,

How to fill out va form 21 0781a

1. The first step to fill out VA Form 21-0781a is to provide your personal information. This includes your full name, Social Security number, date of birth, and contact information.
2. Next, you need to provide information about the incident or stressor that caused your post-traumatic stress disorder (PTSD) or other mental health conditions. You will need to describe the specific events or experiences that contributed to your condition.
3. The form also requires you to provide details about any treatment you have received for your mental health conditions. This includes information about the healthcare providers you have seen and the medications or therapies you have used.
4. Additionally, you need to provide information about any current symptoms you are experiencing. This includes any physical or psychological symptoms that are a result of your PTSD or other mental health conditions.
5. Finally, you should sign and date the form to certify that the information provided is true and accurate to the best of your knowledge.

Who needs VA Form 21-0781a?

1. VA Form 21-0781a is needed by veterans who are applying for disability benefits due to post-traumatic stress disorder (PTSD) or other mental health conditions. This form is specifically designed to collect information about the incidents or stressors that caused the PTSD or mental health condition.
2. Veterans who believe their mental health conditions were caused or worsened by specific traumatic events during their military service should use VA Form 21-0781a to provide the necessary details for their disability claim.
3. It is important to note that this form is not required for all disability claims and is specific to PTSD or mental health conditions related to specific incidents or stressors. Other disability claims may require different forms and documentation.

• Who needs a VA Form 21-0781a?
• What is VA Form 21-0781a for?
• Is VA Form 21-0781a accompanied by other forms?
• • How do I fill out VA Form 21-0781a PDF?
  • Where do I send VA Forms 21-0781a?

Who needs a VA Form 21-0781a?

Form VA 21-0781a, Statement in Support of Claim for Service Connection Post-Traumatic Stress Disorder, should be completed by a military serviceman suffered stressful incident or incidents that occurred in service and are contributed to a person’s current conditions.

What is VA Form 21-0781a for?

The VA Administration will make their own investigation order to assess whether this person is owed any benefits in connection with the incident; based on the information provided the VA will conduct research of military records and other sources identified in this form.

A submitter must provide all available sources (military and non-military) that may provide information concerning reported incident.

Is VA Form 21-0781a accompanied by other forms?

The Statement in Support of Claim for Service Connection Post-Traumatic Stress Disorder should be submitted along with this Statement if you would like the VA to obtain the treatment records from the particular provider.

How do I fill out VA Form 21-0781a PDF?

You should complete the following blocks in order to complete VA PTSD Statement:

• Veteran’s personal information;

• Stressful Incident description (date, location, unit assignment, and dates of the unit assignment);

• Description of the Incident;

• Other Sources of Information;

• Any other information to be important;

Once completed, the form 21 0781a should be signed and dated.

Where do I send VA Forms 21-0781a?

Once completed and signed, this Statement in Support of Claim for Service Connection Post-Traumatic Stress Disorder should be directed to the chain commander or any other person responsible for such an evaluation.

 

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People Also Ask about va form 21 0781a

How do I write a personal statement for sleep apnea?

Personal Statement: You can explain using specific stories about (1) what happened that caused your OSA or worsened the symptoms and (2) how the symptoms began or changed during your time in service.

How to fill out a VA form 21 10210?

How to Fill Out VA Form 21-10210 Full name. Social security number. VA file number. Date of birth. Telephone number. Email address (optional) Mailing address.

What is Type VA 21-0781 statement in support of claim for PTSD?

The Department of Veterans Affairs (VA) uses VA Form 21-0781 to help determine if service connection for PTSD is warranted. Essentially, this form allows veterans to list the traumatic incident or incidents (i.e., stressors) that occurred during military service that led or contributed to their PTSD diagnosis.

What is a VA form 21-0781a?

Use VA Form 21-0781a if you've been diagnosed with PTSD related to or because of personal assault, and you want to apply for related benefits or services.

How do I fill out a VA Form 21-10210?

How to Fill Out VA Form 21-10210 Full name. Social security number. VA file number. Date of birth. Telephone number. Email address (optional) Mailing address.

What is the difference between 21-0781 and 21-0781a?

In order to get a disability rating and subsequent benefits for PTSD, veterans must complete VA Form 21-0781. This is a statement in support of a claim for service connection for PTSD. If your PTSD was the result of physical assault or military sexual trauma, you should use VA Form 21-0781a.

For pdfFiller’s FAQs

What is va form 21 0781a?

VA Form 21-0781a is a form used by the U.S. Department of Veterans Affairs (VA) to collect information from veterans who have experienced a traumatic event or experienced a stressor during their military service. It is titled "Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD) Secondary to Personal Assault." This form is used to gather details about the personal assault experienced by the veteran and is typically required when filing a claim for service connection for PTSD related to personal assault.

Who is required to file va form 21 0781a?

VA Form 21-0781a, also known as the Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD) Secondary to Personal Assault, is typically filed by veterans who are seeking service connection for PTSD caused by a personal assault that took place while they were serving on active duty or in certain other circumstances. This form is specifically for veterans who experienced a personal assault and are seeking disability benefits related to it.

What is the purpose of va form 21 0781a?

The purpose of VA Form 21-0781a is to collect information about a claimant's mental health condition in order to evaluate and determine their eligibility for disability compensation or benefits related to mental health issues. This form is specifically designed to gather information about post-traumatic stress disorder (PTSD) related to personal trauma experiences. It helps the Department of Veterans Affairs (VA) assess the severity of the condition and to determine the appropriate level of compensation or benefits that the claimant may be entitled to receive.

What is the penalty for the late filing of va form 21 0781a?

There is no specific penalty mentioned for the late filing of VA Form 21-0781a (Statement in Support of Claim for PTSD). However, it is always advisable to file your claim and provide any required forms as soon as possible to prevent any possible delays in processing your claim. It is best to contact the Department of Veterans Affairs (VA) directly or consult with a VA representative for more specific information regarding the filing deadline and any potential consequences of late filing.

How to fill out va form 21 0781a?

To fill out VA Form 21-0781a, you can follow these steps: 1. Download VA Form 21-0781a from the official VA website or obtain a physical copy from the nearest VA regional office. 2. Read the instructions section carefully to understand how to complete the form properly. 3. Start by completing the top part of the form, which includes your personal information, such as your name, social security number, and contact details. 4. Move on to Section I: Veteran Identification. Fill out the necessary information related to your military service, such as branch, service number, and dates of service. 5. In Section II: Stressors, describe in detail the traumatic events or experiences that caused or worsened your mental health condition. Be specific and provide as much detail as possible, including dates, locations, and any other relevant information. 6. Section III: Location of Stressor(s) requires you to provide details about where the traumatic events occurred. Include the country, state, city, and any additional information that helps describe the location accurately. 7. In Section IV: Other Information, fill out any additional information that may be relevant to your claim, such as witnesses, medical evidence, or other supporting documentation. 8. If you need additional space to provide more information, continue on blank sheets of paper and make sure to clearly mark which question or section the additional information is referring to. 9. Sign and date the form at the bottom, verifying that the information provided is accurate and complete to the best of your knowledge. 10. Keep a copy of the completed form for your records, and submit the original form to the appropriate VA office or submit it electronically through the VA's online eBenefits portal if available. Remember to double-check your completed VA Form 21-0781a for any errors or missing information before submitting it. If you have any doubts or need assistance, you can contact your local VA office or speak with a representative from a Veterans Service Organization (VSO) who can guide you through the process.

What information must be reported on va form 21 0781a?

VA Form 21-0781a, also known as the "Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD) Secondary to Personal Assault," requires the following information to be reported: 1. Personal Information: The form requires the claimant's full name, Social Security Number, and contact details. 2. Personal Assault Incident: The form asks for detailed information about the personal assault incident, including the date, location, description of the assault, and the relationship between the claimant and the perpetrator. 3. Stressors: It requires the claimant to identify the specific stressor(s) related to the personal assault incident that contributed to their PTSD. This may include physical, sexual, or emotional assault. 4. Service Information: The claimant is asked to provide details about their military service, including dates, branch of service, and specific duty assignments related to the personal assault incident. 5. Medical Treatment: The form asks for information regarding any medical or mental health treatment received as a result of the personal assault incident, including names of healthcare providers, dates of treatment, and medication taken. 6. Impact of PTSD Symptoms: This section requires the claimant to provide a thorough description of the impact of PTSD symptoms on their daily life, work, relationships, and overall well-being. 7. Supporting Evidence: The claimant is asked to provide any available supporting evidence, such as police reports, medical records, letters from witnesses, or any other relevant documents. 8. Signature and Date: The claimant must sign and date the form, certifying that the provided information is true and accurate to the best of their knowledge. It's important to note that this is a general overview, and each individual case may have specific requirements or additional information needed. It is recommended to carefully review the instructions accompanying the form or consult with a VA representative for specific guidance.

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