Va Form 21-0960a-1 - Ischemic Heart Disease (Ihd) Disability Benefits Questionnaire Page 3

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION VI - FUNCTIONAL IMPACT AND REMARKS (Continued)

(If any)

7. REMARKS

SECTION VII - 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. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER

8F. PHYSICIAN'S ADDRESS

NOTE: VA may obtain additional medical information, including an examination, 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

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 required to obtain or

retain benefits. 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 If desired, you can call 1-800-827-1000 to

get information on where to send comments or suggestions about this form.

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VA FORM 21-0960A-1, JUN 2017