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Get AU D2049 2013

Medical diagnosis Basis for diagnosis Is this diagnosis Confirmed Provisional When did the claimant first consult you for this injury or disease Please advise approximate date of onset of the injury or disease based on available notes Address POSTCODE Telephone Medical practitioner stamp Please include Provider Number MEDICAL PRACTITIONER S SIGNATURE Date D2049 - 03/14 - p2 of 2 Save Print Clear. Do not know When did you first notice signs or symptoms of the On what date did you first receive medical treatment for this injury or disease Name of your treating medical practitioner/hospital/ specialist Type of treatment or consultation provided e.g. Has this injury or disease worsened or been aggravated since 1 July Is a medical practitioner s account attached in relation to completion of this injury or disease details sheet if known For claimed conditions D2049 - 4/13 - p1 of 2 Privacy notice Your personal information is protected by law including the Privacy Act 1988. IMPORTANT Injury or disease details sheet Surname Given name s DVA file number s if known This section to be filled in by the claimant Please fill out one sheet per injury or disease for which you are now claiming liability at Question 16. If this is a reassessment do not complete this sheet. Please detail the injury or disease you are now claiming and describe as fully as you can the signs and symptoms that make you notice the disability e*g* pain in lower back shortness of breath loss of range of movement in right arm. You are requested to ask your doctor to fill in the Medical Practitioner section on the next page before lodging your claim* Signs and symptoms How do you believe your service caused contributed to or aggravated this injury or disease If insufficient space please attach a separate sheet When did the injury happen if applicable Has a Defence injury report been completed No Yes Please attach the Defence injury report. Your personal information may be collected by the Department of Veterans Affairs DVA for the delivery of government programs for war veterans members of the Australian Defence Force members of the Australian Federal Police and their dependants. Read more How DVA manages personal information INJURY OR DISEASE DETAILS SHEET continued Please supply a brief summary of the basis for each diagnosis and attach any reports you have that confirm the diagnosis. DVA will pay you for this service according to the relevant fee levels for the service. NOTE The claim for this condition must be lodged before payment of medical account can be made. IMPORTANT Injury or disease details sheet Surname Given name s DVA file number s if known This section to be filled in by the claimant Please fill out one sheet per injury or disease for which you are now claiming liability at Question 16. If this is a reassessment do not complete this sheet. Please detail the injury or disease you are now claiming and describe as fully as you can the signs and symptoms that make you notice the disability e*g* pain in lower back shortness of breath loss of range of movement in right arm. .

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