Get Va 21-0960g-1 2016-2025

The VA 21-0960G-1 form is essential for veterans applying for disability benefits related to esophageal conditions. This guide provides clear and supportive steps to assist users in filling out the form accurately and efficiently online.

Follow the steps to successfully complete the VA 21-0960G-1 form.

1. Press the ‘Get Form’ button to access the VA 21-0960G-1 form and open it for editing.
2. Begin by entering the name of the patient or veteran. You will need to provide the first name, middle initial (if applicable), and last name.
3. Next, fill in the veteran's social security number accurately in the designated field.
4. In Section I, indicate whether the veteran currently has or has ever been diagnosed with an esophageal condition by checking ‘Yes’ or ‘No.’ If ‘Yes,’ complete the subsequent fields regarding diagnoses.
5. List all applicable diagnoses in Item 1B, including gastroesophageal reflux disease (GERD), hiatal hernia, and other relevant conditions. Be sure to input the corresponding ICD codes and dates of diagnosis.
6. Proceed to Section II and provide a summary of the veteran's medical history regarding their esophageal conditions, including the onset and journey of the condition.
7. In Section III, indicate whether the veteran is experiencing relevant signs and symptoms due to esophageal conditions. For each checked symptom, provide any required frequency and duration details.
8. Complete Section IV if applicable, describing any esophageal strictures, spasms, or diverticula. Include the severity of the condition.
9. Section V requires details about any other significant physical findings, complications, signs, or symptoms related to the diagnosis.
10. If diagnostic testing has occurred, fill in Section VI with details about the tests performed, their dates, and results.
11. In Section VII, assess if any esophageal conditions impact the veteran's ability to work and provide examples if applicable.
12. Use Section VIII for any additional remarks that may support the claim.
13. Finally, Section IX requires the physician's certification. Ensure that the physician signs, includes their printed name, phone and fax number, NPI number, and the date signed.
14. Review all entries for accuracy before saving changes. You have options to download, print, or share the completed form.

Complete the VA 21-0960G-1 form online today to ensure your benefits application is submitted without delay.