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.
VA 21-0960M-9 2013-2024 free printable template
Show details
3A. INITIAL ROM MEASUREMENTS Knee RIGHT KNEE All Normal LEFT Joint Movement ROM Measurement Flexion normal endpoint 140 degrees Not indicated Extension If ROM testing is not indicated for the veteran s condition or not able to be performed please explain why and then proceed to Section 5 Not able to perform VA FORM 21-0960M-9 MAY 2013 Page 2 3B. Explain your findings and reasons in comments section. Knee strain Side affected Right Left Both ICD Code Date of diagnosis Knee...
pdfFiller is not affiliated with any government organization
Get, Create, Make and Sign
Edit your yes left va latest form online
Type text, complete fillable fields, insert images, highlight or blackout data for discretion, add comments, and more.
Add your legally-binding signature
Draw or type your signature, upload a signature image, or capture it with your digital camera.
Share your form instantly
Email, fax, or share your yes left va latest form via URL. You can also download, print, or export forms to your preferred cloud storage service.
How to edit yes left va latest online
In order to make advantage of the professional PDF editor, follow these steps below:
1
Log in to your account. Start Free Trial and sign up a profile if you don't have one yet.
2
Simply add a document. Select Add New from your Dashboard and import a file into the system by uploading it from your device or importing it via the cloud, online, or internal mail. Then click Begin editing.
3
Edit yes va both blank form. Rearrange and rotate pages, insert new and alter existing texts, add new objects, and take advantage of other helpful tools. Click Done to apply changes and return to your Dashboard. Go to the Documents tab to access merging, splitting, locking, or unlocking functions.
4
Save your file. Choose it from the list of records. Then, shift the pointer to the right toolbar and select one of the several exporting methods: save it in multiple formats, download it as a PDF, email it, or save it to the cloud.
pdfFiller makes working with documents easier than you could ever imagine. Create an account to find out for yourself how it works!
VA 21-0960M-9 Form Versions
Version
Form Popularity
Fillable & printabley
Video instructions and help with filling out and completing yes left va latest
Instructions and Help about veteran normal millimeters template form
Fill va both millimeters fill : Try Risk Free
For pdfFiller’s FAQs
Below is a list of the most common customer questions. If you can’t find an answer to your question, please don’t hesitate to reach out to us.
How can I edit yes left va latest on a smartphone?
You can do so easily with pdfFiller’s applications for iOS and Android devices, which can be found at the Apple Store and Google Play Store, respectively. Alternatively, you can get the app on our web page: https://edit-pdf-ios-android.pdffiller.com/. Install the application, log in, and start editing yes va both blank form right away.
How do I fill out the va any millimeters blank form on my smartphone?
On your mobile device, use the pdfFiller mobile app to complete and sign side veteran millimeters printable. Visit our website (https://edit-pdf-ios-android.pdffiller.com/) to discover more about our mobile applications, the features you'll have access to, and how to get started.
How do I edit left joint veteran online on an Android device?
With the pdfFiller mobile app for Android, you may make modifications to PDF files such as normal movement veteran create form. Documents may be edited, signed, and sent directly from your mobile device. Install the app and you'll be able to manage your documents from anywhere.
Fill out your yes left va latest online with pdfFiller!
pdfFiller is an end-to-end solution for managing, creating, and editing documents and forms in the cloud. Save time and hassle by preparing your tax forms online.
Va Any Millimeters Blank is not the form you're looking for?Search for another form here.
Keywords relevant to indicated veteran able download form
Related to va knee lower conditions
If you believe that this page should be taken down, please follow our DMCA take down process
here
.