IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY

IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY

1 Pages · 2015 · 2.79 MB · English

sleep apnea disability benefits questionnaire. 1b. provide only diagnoses that pertain to sleep apnea and check diagnostic type: (if "yes," list only those

IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY free download


SLEEP APNEA DISABILITY BENEFITS QUESTIONNAIRE 1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO SLEEP APNEA AND CHECK DIAGNOS\ TIC TYPE: (If "Yes," list only those medications required for the veteran's sleep\ disorder condition): 2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF A SLEEP DISORDER CO\ NDITION?1A. DOES THE VETERAN HAVE OR HAS HE OR SHE EVER HAD SLEEP APNEA? OMB Control No. 2900-0778 Respondent Burden: 15 Minutes Expiration Date: 09/30/2019 4B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLIC\ ATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY CONDITIONS LISTED IN THE DIAGNOSIS SECTION?OTHER SLEEP DISORDER (specify): CENTRAL OBSTRUCTIVE 3. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRI\ BUTABLE TO SLEEP APNEA? SECTION II - MEDICAL HISTORY 2C. DOES THE VETERAN REQUIRE THE USE OF A BREATHING ASSISTANCE DEVICE SU\ CH AS A CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) MACHINE? 1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO A DIAGNOSIS OF SLE\ EP APNEA, LIST USING ABOVE FORMAT: (If, "Yes," describe - brief summary): Persistent daytime hypersomnolence (If, "Yes," check all that apply) SECTION IV - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIO\ NS, SIGNS AND/OR SYMPTOMS Other, describe: Requires tracheostomy MIXED, COMPONENTS OF BOTH Evidence of chronic respiratory failure with carbon dioxide retention Cor pulmonale NOTE - The diagnosis of sleep apnea must be confirmed by a sleep study, provid\ e the sleep study results in Section V, Diagnostic Testing. If other res\ piratory condition is diagnosed, complete VA Form 21-0960L-1, Respiratory Conditions Disability Benefits Questionnair\ e and/or VA Form 21-0960C-6, Narcolepsy Disability Benefits Questionnair\ e in lieu of this one. IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE  ANY EXPENSES OR COST INCURRED IN THE PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT \ BURDEN INFORMATION BEFORE COMPLETING FORM. NOTE TO PHYSICIAN  - Your patient is applying to the U.S. Department of Veterans Affair\ s (VA)

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