Get What Is The Simple 12 Form 21

Navigating the process of filling out the What Is The Simple 12 Form 21 online can seem daunting, but with this comprehensive guide, you will find clear and supportive instructions. This guide will help you understand each component of the form and provide you with detailed steps for successful completion.

Follow the steps to complete the Simple 12 Form 21 online.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Begin with providing the patient or veteran's name and Social Security number in the designated fields.
3. In Section I, answer whether the veteran has ever been diagnosed with any male reproductive system conditions. If 'Yes', indicate all diagnoses and provide the corresponding ICD codes and dates of diagnosis.
4. Section II requires you to describe the veteran's medical history of their male reproductive organ conditions, including the treatment plan and any medications being taken.
5. Continue to Section III where you will specify any voiding dysfunction, including details about urinary leakage, appliance use, and frequency of urination.
6. Section IV focuses on urinary tract or kidney infections, where you will indicate if there is a history of such infections and describe any treatments received.
7. In Section V, indicate if the veteran has erectile dysfunction and provide additional details and any treatment information.
8. Proceed to Section VI for information regarding retrograde ejaculation, if applicable.
9. Continue to Section VII, indicating any history of chronic infections related to male reproductive organs, detailing treatments used.
10. In Section VIII, provide information from the physical examination of the male reproductive system, including abnormalities if found.
11. Section IX pertains to any neoplasms related to previous diagnoses. Indicate the type of neoplasm and treatments undertaken.
12. Fill in Section X to report any additional physical findings or complications.
13. In Section XI, provide details on any diagnostic testing performed, including results.
14. Finally, in Section XII, describe how the veteran's condition impacts their ability to work.
15. Complete the physician's certification and ensure all required signatures and details are filled out. Save your changes, download, or print the completed form as needed.

Start completing your Simple 12 Form 21 online today to ensure your claim is processed efficiently.