Va Form 21-0960m-1 - Amputations Disability Benefits Questionnaire
Download a blank fillable Va Form 21-0960m-1 - Amputations Disability Benefits Questionnaire in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Va Form 21-0960m-1 - Amputations Disability Benefits Questionnaire with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4OMB Approved No. 2900-0776
Respondent Burden: 30 Minutes
Expiration Date: 11/30/2017
AMPUTATIONS
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. VA reserves the right to confirm the authenticity of ALL DBQ's completed
by private health care providers.
NOTE: If the following are noted, complete the appropriate disability questionnaire.
1. For limited motion or instability in the joint above the amputation site, also complete the Disability Benefits Questionnaire for the specific joint.
2. For scars, or skin breakdown also complete the VA Form 21-0960F-1, Scars Disability Benefits Questionnaire.
3. For muscular injuries, also complete VA Form 21-0960M-10, Muscle Injury Disability Benefits Questionnaire.
4. For Osteomyelitis, also complete the VA Form 21-0960M-11, Osteomyelitis Disability Benefits Questionnaire.
5. For circulation conditions related to amputation, also complete VA Form 21-0960A-2, Arteries and Veins Disability Benefits Questionnaire.
6. For painful neuroma, also complete VA Form 21-0960C-10, Peripheral Nerve Disability Benefits Questionnaire.
SECTION I - DIAGNOSIS
1A. HAS AN AMPUTATION(S) BEEN PERFORMED?
(If "Yes," complete Item 1B)
YES
NO
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO AMPUTATION(S)
AMPUTATION # 1 -
ICD CODE -
DATE OF AMPUTATION -
AMPUTATION # 2 -
ICD CODE -
DATE OF AMPUTATION -
AMPUTATION # 3 -
ICD CODE -
DATE OF AMPUTATION -
1C. IF ADDITIONAL AMPUTATION(S) EXIST, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
2. DESCRIBE THE ETIOLOGY OF EACH AMPUTATION LISTED IN SECTION I:
SECTION III - DOMINANT HAND
3. DOMINANT HAND
RIGHT
LEFT
AMBIDEXTROUS
SECTION IV - AMPUTATION(S) SITE(S)
(Check all that apply):
4. AMPUTATION(S) SITE(S)
(not including the fingers)
UPPER EXTREMITIES
FINGERS
(including the forefoot)
LOWER EXTREMITIES
TOES
(If checked, complete the appropriate section below)
NOTE - Imaging studies are not required to document amputation(s)
SECTION V - AMPUTATION(S) OF THE UPPER EXTREMITY(IES) (NOT INCLUDING FINGERS)
5A. IS THERE AN AMPUTATION OF EITHER ARM?
(If "Yes," check all that apply)
YES
NO
LEFT
RIGHT
Amputation is below insertion of deltoid
Amputation is below insertion of deltoid
Amputation is above insertion of deltoid
Amputation is above insertion of deltoid
Disarticulation
Disarticulation
Does the amputation site allow the use of a suitable
Does the amputation site allow the use of a suitable
prosthetic appliance?
prosthetic appliance?
YES
NO
YES
NO
VA FORM
21-0960M-1
SUPERSEDES VA FORM 21-0960M-1, OCT 2012,
Page 1
DEC 2014
WHICH WILL NOT BE USED.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal