Follow the steps to complete the 21 0960n 4 form successfully.

1. Select the ‘Get Form’ button to obtain the 21 0960n 4 form and access it in the editable format.
2. Begin filling out Section I - Diagnosis by providing the patient or veteran's name and social security number. Confirm whether a sinus, nose, throat, larynx, or pharynx condition has been diagnosed.
3. In Section I, continue to select the veteran's specific conditions by checking the appropriate boxes and entering the corresponding ICD codes and diagnosis dates.
4. Move to Section II - Medical Record Review. Indicate which medical records have been reviewed, specifying if they are from a VA file or other sources.
5. Proceed to Section III - Medical History to describe the history of the veteran's condition. If continuous medication is required, list the medications.
6. In Section IV, check any symptoms related to the veteran's condition, including whether there is a need for additional examinations or if any significant physical findings exist.
7. Complete Section V - Diagnostic Testing if any imaging or endoscopic procedures were performed. Record the type of tests, dates, and results.
8. Use Section VI - Functional Impact to describe how the veteran's conditions affect their ability to work. Provide examples as necessary.
9. In Section VII - Remarks, add any additional comments relevant to the veteran's condition or medical history.
10. Finally, in Section VIII - Physician's Certification and Signature, the physician must print their name, sign, and provide contact information before submitting the form. Make sure to submit to the appropriate VA Regional Office.

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