VA 21-0960M-9 2013-2024 free printable template

S. Department of Veterans Affairs and you must have authorization and permission for VA to collect information. Name of Service Members Service or Agency (if known) PHYSICIAN RESPONSE. NAME OF PHYSICIAN PHYSICIAN'S RESPONSE. MAJOR MEDICAL DISABILITY OR SURGERY REQUIREMENT: MEDICAL INFORMATION ONLY: If the veteran requests that the doctor's information be kept confidential, provide: Patient/Veteran's Social Security Number Veteran/Service member's Military Service Number Service or agency's name Veterans Information Exchange Number (VISA) SUMMARY INFORMATION: PHYSICIAN'S RESPONSE: NAME OF PHYSICIAN: NAME OF PATIENT or VETERAN DETAILS PROVIDED AS FOLLOWS: Name of surgeon Medical Specialty of surgery If surgery is not listed on this form, list surgical specialty and the date (e.g. April 2017) If surgery is listed on this form, indicate the date (e.g. April 2017) Date of surgery LAST OF THE FOLLOWING CERTIFICATES MADE APPOINTMENT BY: Name of surgeon Medical specialty of surgery Date (e.g. April 2017) LAST OF THE FOLLOWING CERTIFICATES DEALT WITH: Name of surgeon Medical specialty of surgery Date of surgery Note: If patient/Veteran lists two doctors from two different medical specialties, state which physician performed the surgery. Name of surgeon Medical specialty of surgery Date of surgery OTHER NAME AVAILABLE ON FILE Medical Practice Information Other Personal Information Physician's Email Address PHYSICIAN'S ADDRESS: Note — If patient/Veteran lists more than one physician (or practice) with the same first name, identify the physician who performed the surgery on their record. Fee of 0.00 Allowing VA to obtain a copy of the veterans' official records is a privilege under federal law and is not a fee.