Get Va Form 21-0960a-4 2011-2026

Filling out the VA Form 21-0960A-4, the non-ischemic heart disease disability benefits questionnaire, is an essential step for veterans seeking disability benefits. This guide will provide you with clear, step-by-step instructions to complete the form online, ensuring you have all the necessary information at hand.

Follow the steps to complete the form accurately and efficiently.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the name of the patient or veteran in the designated field, followed by their social security number. This information is crucial for identifying the individual applying for benefits.
3. In Section I - Diagnosis, respond to the question regarding the presence of non-ischemic heart disease, arrhythmias, or cardiac surgery. Select 'Yes' or 'No' and proceed accordingly. If 'Yes,' fill in the diagnosis, ICD code, and date of diagnosis for the relevant conditions.
4. Move to Section II - Medical History. Answer whether the veteran has heart disease and specify any conditions that apply. For each condition listed, provide additional information as required, including treatment history.
5. Continue to Section III - Medical History Treatment. Indicate if the veteran's treatment plan includes continuous medication and if there is a history of specific heart-related interventions. Provide details about the treatment facilities and dates as applicable.
6. In Section IV - Congestive Heart Failure (CHF), answer whether the veteran has CHF, and specify if it is chronic or had multiple episodes in the past year. Include treatment facility details where necessary.
7. Proceed to Section V - Cardiac Functional Assessment. Indicate whether a diagnostic exercise test was conducted previously. If so, provide the level of METs the veteran can perform and the date of the test. If not, fill out the METs test based on the veteran's reported symptoms.
8. In Section VI - Diagnostic Testing, report any evidence of cardiac hypertrophy or dilatation, including details from the most recent tests conducted, such as EKG or echocardiogram.
9. In Section VII - Functional Impact and Remarks, describe how the veteran's heart disease impacts their ability to work, providing specific examples.
10. Finally, in Section VIII - Physician's Certification and Signature, your physician will need to sign and fill in their details. Ensure all fields are completed accurately before submitting.
11. After completing the form, you may save changes, download, print, or share the form as needed to maintain a record.

Take the next step in your benefits application by completing the VA Form 21-0960A-4 online today.