Fillable Printable Vba 21 0960A 3 Are

Vba 21 0960A 3 Are

NOTE: ALSO complete appropriate questionnaires for hypertension-related complications, if any (such as VA Form 21-0960J-1, Kidney Conditions (Nephrology)

Disability Benefits Questionnaire , if renal insufficiency is attributable to hypertension.)

HYPERTENSION DISABILITY BENEFITS QUESTIONNAIRE

2E. CURRENT BLOOD PRESSURE READINGS (SUFFICIENT IF VETERAN HAS A PREVIOUSLY ESTABLISHED DIAGNOSIS OF HYPERTENSION.)

2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR HYPERTENSION OR ISOLATED SYSTOLIC HYPERTENSION?

2C. WAS THE VETERAN'S INITIAL DIAGNOSIS OF HYPERTENSION OR ISOLATED SYSTOLIC HYPERTENSION CONFIRMED BY BLOOD PRESSURE READINGS

TAKEN 2 OR MORE TIMES ON AT LEAST 3 DIFFERENT DAYS?

2D. DOES THE VETERAN HAVE A HISTORY OF A DIASTOLIC BP ELEVATION TO PREDOMINANTLY 100 OR MORE?

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.

(If, "Yes," provide BP readings used to establish initial diagnosis, if known.)

(If "No," report BP readings taken 2 or more times on at least 3 different days in order to confirm diagnosis (unless veteran

is on treatment for hypertension.)

OMB Approved No. 2900-0776

Respondent Burden: 15 Minutes

Expiration Date: 11/30/2017

SECTION I - DIAGNOSIS

READING # 3:

2A. DESCRIBE THE HISTORY (INCLUDING ONSET AND COURSE) OF THE VETERAN'S HYPERTENSION CONDITION

(Brief summary):

SECTION II - MEDICAL HISTORY

UNKNOWNYES

YES NO

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.

READING # 1:

READING # 2:

YES

DATE OF READING:

1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH HYPERTENSION OR ISOLATED SYSTOLIC HYPERTENSION BASED ON

THE FOLLOWING CRITERIA?

NOTE: For VA disability rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic

hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. For VA purposes, the

INITIAL diagnosis of hypertension or isolated systolic hypertension must be confirmed by readings taken 2 or more times on at least 3 different days. Blood pressure

results may be obtained from existing medical records or through scheduled visits for blood pressure measurements.

READING # 1: READING # 2:

DATE OF READING:

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

NAME OF PATIENT/VETERAN

Page 1

21-0960A-3

VA FORM

DEC 2014

(If "Yes," provide only diagnoses that pertain to hypertension):

NOYES

1B. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO HYPERTENSION OR ISOLATED SYSTOLIC HYPERTENSION, LIST USING ABOVE FORMAT:

(If "Yes," list only those medications used for the diagnosed conditions):

(If "Yes," describe frequency and severity of diastolic BP elevation):

Hypertension

Isolated systolic hypertension

Other, specify:

ICD code: Date of diagnosis:

ICD code:

Date of diagnosis:ICD code:

Date of diagnosis:

Date of diagnosis:ICD code:

Other diagnosis #2:

Other diagnosis #1:

SUPERSEDES VA FORM 21-0960A-3, OCT 2012,

WHICH WILL NOT BE USED.

SECTION III - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS

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 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 www.reginfo.gov/public/do/PRAMain

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

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

3A. DOES THE VETERAN HAVE ANY SCARS (SURGICAL OR OTHERWISE) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS

LISTED IN SECTION I, DIAGNOSIS?

YES NO

(If "Yes," complete Item 3B)

6C. DATE SIGNED

6E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER 6F. PHYSICIAN'S ADDRESS

6B. PHYSICIAN'S PRINTED NAME

(VA Regional Office FAX No.)

6A. PHYSICIAN'S SIGNATURE

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

NOTE - A list of VA Regional Office FAX Numbers can be found at www.benefits.va.gov/disabilityexams or obtained by calling 1-800-827-1000.

SECTION VI - PHYSICIAN'S CERTIFICATION AND SIGNATURE

IMPORTANT - Physician please fax the completed form to

6D. PHYSICIAN'S PHONE AND FAX NUMBER

NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.

5. REMARKS (If any)

VA FORM 21-0960A-3, DEC 2014

Page 2

3B. ARE ANY OF THE SCARS PAINFUL AND/OR UNSTABLE, OR IS THE TOTAL AREA OF ALL RELATED SCARS GREATER THAN OR EQUAL TO 39 SQUARE CM

(6 SQUARE INCHES)?

YES NO

(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)

3C. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO THE

CONDITION(S) LISTED IN SECTION I, DIAGNOSIS?

YES NO

(If "Yes," describe-brief summary)

SECTION IV - FUNCTIONAL IMPACT

4. DOES THE VETERAN'S HYPERTENSION OR ISOLATED SYSTOLIC HYPERTENSION IMPACT HIS OR HER ABILITY TO WORK?

YES NO

(If "Yes," describe the impact of the veteran's hypertension or isolated systolic hypertension, providing one or more examples):

SECTION V - REMARKS

PATIENT/VETERAN'S SOCIAL SECURITY NO.