Va Form 21-0960g-7 - Stomach And Duodenal Conditions (Not Including Gerd Or Esophageal Disorders) Disability Benefits Questionnaire Page 5

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SECTION IX - REMARKS

(If any)

9. REMARKS

SECTION X - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.

10A. PHYSICIAN'S SIGNATURE

10B. PHYSICIAN'S PRINTED NAME

10C. DATE SIGNED

10D. PHYSICIAN'S PHONE AND FAX NUMBER

10E. PHYSICIAN'S MEDICAL LICENSE NUMBER

10F. PHYSICIAN'S ADDRESS

NOTE - VA may request additional medical information, including additional examinations 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, 58VA21/22/28, 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 15 minutes to review the instructions, find the information, and complete a 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 21-0960G-7, OCT 2012