Va Form 21-0960a-4 - Heart Conditions (Including Ischemic And Non-Ischemic Heart Disease, Arrhythmias, Valvular Disease And Cardiac Surgery) Disability Benefits Questionnaire Page 7

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SECTION XV - FUNCTIONAL IMPACT
15. DOES THE VETERAN'S HEART CONDITION(S) IMPACT HIS OR HER ABILITY TO WORK?
(If "Yes," describe impact of each of the veteran's heart conditions, providing one or more examples)
YES
NO
SECTION XVI - REMARKS
(If any)
16. REMARKS
SECTION XVII - PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
17A. PHYSICIAN'S SIGNATURE
17B. PHYSICIAN'S PRINTED NAME
17C. DATE SIGNED
17D. PHYSICIAN'S PHONE NUMBER
17E. PHYSICIAN'S MEDICAL LICENSE NUMBER
17F. 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 voluntary. 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 30 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.
Page 7
VA FORM 21-0960A-4, OCT 2012

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