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The VA Form 21-0960C-8 is a crucial tool for veterans seeking disability benefits related to headache conditions, including migraines. This form is designed to gather detailed information about the veteran's diagnosis, medical history, symptoms, and functional impact of their headache condition. Each section prompts the medical professional to provide specific answers about the veteran's experiences, such as the types and frequency of headaches, the effectiveness of treatment plans, and any related complications. Additionally, there are sections that address the impact of headaches on the veteran's work capabilities and daily life. The form stresses the importance of accurate and complete information, as the Department of Veterans Affairs will use these details to assess the claim effectively. It is essential to remember that any expenses incurred during the completion of this form will not be reimbursed by the VA. Privacy is emphasized throughout the process, ensuring that the veteran's personal information remains confidential in accordance with applicable regulations.

Va 21 0960C 8 Example

OMB Control No. 2900-0778

Respondent Burden: 15 minutes

HEADACHES (INCLUDING MIGRAINE HEADACHES)

DISABILITY BENEFITS QUESTIONNAIRE

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 THIS FORM.

NAME OF PATIENT/VETERAN

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you provide on this questionnaire as part of their evaluation in processing the veteran's claim.

SECTION I - DIAGNOSIS

1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A HEADACHE CONDITION?

 

 

 

 

 

YES

 

NO (If "Yes," complete Item 1B)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1B. SELECT THE VETERAN'S CONDITION (check all that apply):

 

 

 

 

 

 

 

Migraine including migraine variants

ICD Code:

 

Date of Diagnosis:

 

 

 

 

 

 

Tension

 

 

 

 

ICD Code:

 

Date of Diagnosis:

 

 

 

 

 

 

 

 

 

 

Cluster

 

 

 

 

ICD Code:

 

Date of Diagnosis:

 

 

 

 

 

 

 

 

 

 

Other (specify type of headache):

 

ICD Code:

 

Date of Diagnosis:

 

 

 

 

Other Diagnosis #1:

 

ICD Code:

 

Date of Diagnosis:

 

 

Other Diagnosis #2:

 

ICD Code:

 

Date of Diagnosis:

 

 

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO A HEADACHE CONDITION, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY

2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S HEADACHE CONDITIONS (brief summary):

2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING MEDICATION FOR THE DIAGNOSED CONDITION?

 

YES

 

NO IF YES, DESCRIBE TREATMENT (list only those medications used for the diagnosed condition):

SECTION III - SYMPTOMS

3A. DOES THE VETERAN EXPERIENCE HEADACHE PAIN?

YES NO

(If "Yes," check all that apply to headache pain):

Constant head pain

Pulsating or throbbing head pain

Pain localized to one side of the head

Pain on both sides of the head

Pain worsens with physical activity

Other, describe:

OCT 2012 21-0960C-8

WHICH WILL NOT BE USED.

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VA FORM

SUPERSEDES VA FORM 21-0960C-8, FEB 2011,

 

SECTION III - SYMPTOMS (Continued)

3B. DOES THE VETERAN EXPERIENCE NON-HEADACHE SYMPTOMS ASSOCIATED WITH HEADACHES? (Including symptoms associated with an aura prior to

headache pain)

YES

NO

(If "Yes," check all that apply):

Nausea

Vomiting

Sensitivity to light

Sensitivity to sound

Changes in vision (such as scotoma, flashes of light, tunnel vision)

Sensory changes (such as feeling of pins and needles in extremities)

Other, describe:

3C. INDICATE DURATION OF TYPICAL HEAD PAIN

Less than 1 day 1-2 days

More than 2 days Other, describe:

3D. INDICATE LOCATION OF TYPICAL HEAD PAIN

Right side of head

Left side of head

Both sides of head

Other, describe:

SECTION IV - PROSTRATING ATTACKS OF HEADACHE PAIN

4A. MIGRANE - DOES THE VETERAN HAVE CHARACTERISTIC PROSTRATING ATTACKS OF MIGRAINE HEADACHE PAIN?

YES NO

(If "Yes," indicate frequency, on average, of prostrating attacks over the last several months):

Less than once every 2 months

Once in 2 months

Once every month

More frequently than once per month

4B. DOES THE VETERAN HAVE VERY FREQUENT PROSTRATING AND PROLONGED ATTACKS OF MIGRAINE HEADACHE PAIN?

 

 

YES

 

NO

 

 

 

 

 

4C. NON-MIGRAINE - DOES THE VETERAN HAVE PROSTRATING ATTACKS OF NON-MIGRAINE HEADACHE PAIN?

 

 

YES

 

NO

 

 

 

(If "Yes," indicate frequency, on average, of prostrating attacks over the last several months):

Less than once every 2 months

Once in 2 months

Once every month

More frequently than once per month

4D. DOES THE VETERAN HAVE VERY FREQUENT PROSTRATING AND PROLONGED ATTACKS OF NON-MIGRAINE HEADACHE PAIN?

YES NO

SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS

5A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN DIAGNOSIS, SECTION 1?

YES NO

(If "Yes," are any of the scars painful and/or unstable, or is the total area of all related scars greater than or equal to 39 square cm (6 square inches))?

YES NO

(If "Yes," also complete VA Form 21-0960F-1 Scars/Disfigurement Disability Benefits Questionnaire.)

5B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY CONDITIONS LISTED IN SECTION 1, DIAGNOSIS?

YES

NO

(If "Yes," describe in a brief summary):

VA FORM 21-0960C-8, OCT 2012

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SECTION VI - DIAGNOSTIC TESTING

NOTE: Diagnostic testing is not requested for this examination report; if studies have already been completed, provide the most recent results below.

6.ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS? YES NO

IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS (brief summary):

 

 

 

 

SECTION VII - FUNCTIONAL IMPACT

7. DOES THE VETERAN'S HEADACHE CONDITION IMPACT HIS OR HER ABILITY TO WORK?

 

 

YES

 

NO (If "Yes," describe impact of the veteran's headache condition, providing one or more examples):

 

 

 

SECTION VIII - REMARKS

8. REMARKS (If any)

SECTION IX - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.

9A. PHYSICIAN'S SIGNATURE

9B. PHYSICIAN'S PRINTED NAME

9C. DATE SIGNED

9D. PHYSICIAN'S PHONE AND FAX NUMBER

9E. PHYSICIAN'S MEDICAL LICENSE NUMBER

9F. PHYSICIAN'S ADDRESS

NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.

IMPORTANT - Physician please fax the completed form to

(VA Regional Office FAX No.)

NOTE - A list of VA Regional Office FAX Numbers can be found at www.benefits.va.gov/disabilityexams or obtained by calling 1-800-827-1000.

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.

RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete a form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

VA FORM 21-0960C-8, OCT 2012

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Form Characteristics

Fact Name Description
Purpose The VA Form 21-0960C-8 is used by veterans to apply for disability benefits related to headache conditions, including migraines.
Estimated Completion Time Respondents are estimated to take about 15 minutes to complete the form.
OMB Control Number The form is assigned the OMB Control Number 2900-0778, which is necessary for compliance with Federal regulations.
Privacy Act Notice The form includes a Privacy Act notice, ensuring confidential handling of information provided by the veteran.
Sections Overview The form consists of multiple sections, including diagnosis, medical history, symptoms, and functional impact of headaches.
Related Conditions Veterans can report various types of headache conditions, including migraines, tension headaches, and cluster headaches.
Physician's Certification A physician must certify the information contained in the form, confirming its accuracy and completeness.
Governing Laws This form is governed by Title 38 of the United States Code, which outlines VA benefits and eligibility criteria.

Guidelines on Utilizing Va 21 0960C 8

Once you have gathered the necessary information, you can move on to filling out the VA Form 21-0960C-8. This form is used to apply for disability benefits related to headache conditions. Completing the form accurately is crucial for processing your application efficiently.

  1. Patient Information: Start by entering the name of the patient (veteran) and their Social Security Number at the top of the form.
  2. Diagnosis Section:
    • Answer whether the veteran has ever been diagnosed with a headache condition by checking "Yes" or "No."
    • If "Yes," indicate the type of headache condition by checking all that apply (e.g., Migraine, Tension, Cluster) and provide the relevant ICD Codes and Dates of Diagnosis.
    • If there are additional diagnoses, list them in the same format.
  3. Medical History: Describe the medical history related to the veteran's headache conditions, including onset and course, in a brief summary. Indicate if the treatment plan includes medications for the headache condition and describe them if applicable.
  4. Symptoms Section:
    • State if the veteran experiences headache pain. If "Yes," check all applicable pain descriptions (e.g., Constant, Pulsating, etc.).
    • Indicate if the veteran experiences non-headache symptoms associated with the headaches. If "Yes," check all that apply.
    • Indicate the duration of typical head pain and its location.
  5. Prostrating Attacks:
    • For migraines, answer whether the veteran has characteristic prostrating attacks and indicate their frequency.
    • Answer if there are non-migraine prostrating attacks, documentation of frequency if applicable.
  6. Physical Findings:
    • Indicate whether the veteran has any related scars and whether they are painful or unstable.
    • Describe any other relevant physical findings or symptoms.
  7. Diagnostic Testing: Specify if there are any significant diagnostic test findings. Provide details if applicable.
  8. Functional Impact: Describe how the veteran's headache condition impacts their ability to work if applicable.
  9. Remarks: Include any additional comments or information if necessary.
  10. Physician's Certification: The physician must sign and provide their printed name, date, contact information, medical license number, and address at the end of the form.

Ensure all sections are completed accurately and truthfully. After filling out the form, it’s ready to be submitted. The physician should fax it to the designated VA Regional Office. Utilizing the resources available will help ensure the application is processed smoothly.

What You Should Know About This Form

What is the purpose of the VA Form 21-0960C-8?

This form is designed for veterans seeking disability benefits for headache conditions, including migraines. It helps the Department of Veterans Affairs (VA) gather important medical information from your physician. The data collected will support your claim for benefits related to headaches.

Who needs to complete this form?

The veteran's physician must complete this form. The information provided answers specific questions about the veteran’s headache condition, medical history, symptoms, and treatment. It’s essential for the physician to provide accurate and current information to assist in the claim evaluation.

Are there any costs associated with completing the form?

No, there are no costs that the VA will cover for filling out or submitting this form. It is advised that you review the details carefully to avoid any unnecessary expenses while seeking benefits related to headache conditions.

What should I include in the medical history section?

In the medical history section, describe the onset and course of the veteran's headache condition. Include any significant details, such as when the headaches started, their frequency, and how they have changed over time. This information is crucial for the VA to assess the severity of the condition.

How does the form affect the claim process?

Completing this form accurately is vital for your claim. The information provided will be reviewed by the VA to determine eligibility for benefits. Any missing or inaccurate details could delay the process or affect the outcome, so ensure it is filled out thoroughly.

Common mistakes

Filling out the VA Form 21-0960C-8, which is used to apply for disability benefits related to headaches, can seem straightforward. However, many people make critical mistakes that can delay processing or lead to denials. One common error occurs when applicants fail to provide a complete medical history. Section II asks for a description of the veteran's headache condition history, including when it started and how it has progressed. Without a clear narrative, the reviewing physician may struggle to understand the severity and impact of the condition, potentially affecting the overall assessment.

Another mistake is neglecting to indicate the presence of non-headache symptoms correlated with headaches. In Section III, there is a specific question about whether the veteran experiences symptoms such as nausea or sensitivity to light. These symptoms can be vital for understanding the full scope of the headache condition. Skipping this section or providing insufficient detail could undermine the claim.

Some applicants also overlook the frequency of prostrating attacks, especially regarding migraine attacks in Section IV. Stating "few" or "sometimes" without a precise frequency does not provide the required details. The Department of Veterans Affairs needs to know how often these debilitating episodes occur to evaluate the level of impact on the veteran’s daily life properly.

Finally, failing to ensure all sections of the form are complete before submission is a frequent oversight. While some may believe they have included enough information, incomplete responses can lead to requests for additional documentation or, even worse, a denial of benefits. Attention to detail is essential when filling out this form. Each section serves a purpose and contributes to a comprehensive view of the veteran's health condition.

Documents used along the form

The VA Form 21-0960C-8 is a crucial document for veterans seeking to claim disability benefits related to headache disorders, including migraines and tension headaches. In addition to completing this form, several other documents often play a vital role in supporting the veteran's claim. Below is a list of forms and documents that may be required or beneficial during this process.

  • VA Form 21-526EZ: This is the application for disability compensation and related compensation benefits. Veterans must complete this form to formally apply for disability benefits related to their service-connected conditions.
  • VA Form 21-4138: Known as the Statement in Support of Claim, this form allows veterans to provide additional information, evidence, or personal statements that support their disability claim.
  • VA Form 21-0958: This is an Appeal Form for veterans to use if they disagree with a decision made by the VA regarding their claim. It is essential for ensuring that veterans' voices are heard in the appeals process.
  • VA Form 21-0779: This form is for scheduling an appointment for a disability examination. Veterans may need to undergo further medical evaluations as part of the claims process, and this form facilitates that scheduling.
  • Medical Records: Comprehensive medical records from healthcare providers, including doctors’ notes, treatment plans, and prescription details, provide critical evidence for the assessment of the veteran's headache condition and its impact on daily life.
  • Diagnostic Test Results: Reports from any diagnostic tests related to the headache condition can strengthen a claim. These may include MRI, CT scans, or other relevant imaging studies that provide objective evidence of the condition.
  • Buddy Statements: Affidavits or letters from friends, family, or fellow service members who can attest to the veteran’s symptoms and their effects on daily functioning can offer significant support for the claim.

Submitting comprehensive documentation along with the VA Form 21-0960C-8 can significantly enhance the chances of a successful outcome. It assists the VA in understanding the full context of the veteran's health condition, ultimately facilitating a more informed decision on the disability claim. Veterans should feel empowered to gather and present their information thoroughly and clearly.

Similar forms

The VA Form 21-0960C-8 is a questionnaire that helps veterans document their headache conditions for disability benefits. Several other forms serve similar purposes in gathering specific medical information regarding different health issues. Here are five forms comparable to the VA 21-0960C-8:

  • VA Form 21-0960F-1: This form focuses on scars and disfigurements. Just like the headache questionnaire, it allows the physician to detail the scar’s characteristics, including severity and impact on daily life.
  • VA Form 21-0960G-1: Used for evaluating respiratory conditions, this form collects comprehensive medical history and current symptoms. It shares a similar structure and approach to assessing the condition’s effects on the veteran's daily activities.
  • VA Form 21-0960P-1: This document is dedicated to mental health conditions. Like the headache form, it collects detailed information regarding symptoms, diagnosis history, and functional impact on work and daily life.
  • VA Form 21-0960E-1: This form is aimed at issues related to the intestines. Similar to the headache questionnaire, it requires extensive medical history and treatment plans, allowing for a thorough assessment of the veteran’s condition.
  • VA Form 21-0960N-1: This questionnaire is for evaluating neurological disorders. Its design and intent parallel the VA 21-0960C-8, gathering detailed diagnosis information and the associated impact on the veteran’s quality of life.

Each of these forms plays an important role in helping veterans provide essential information about their health conditions, contributing to the evaluation process for receiving appropriate benefits.

Dos and Don'ts

When filling out the VA Form 21-0960C-8, there are certain steps that can help ensure the process goes smoothly. Here’s a guide on what to do and what to avoid.

  • Do: Carefully read the instructions before starting. Understanding the form's requirements can save you time.
  • Do: Provide accurate and up-to-date information. This includes any recent diagnoses or treatment plans relevant to your headache condition.
  • Do: Use specific medical terms where possible. Clear descriptions of symptoms, treatment history, and medical findings will enhance the clarity of your submission.
  • Do: Keep things organized. Use the spaces provided for each section without mixing details between different questions.
  • Don't: Rush through the form. Take your time to ensure accuracy, as mistakes can lead to delays in processing your claim.
  • Don't: Leave questions unanswered. If a question doesn't apply, indicate that rather than skipping it entirely.

By following these tips, you can help facilitate a more efficient review of your application. Make sure to double-check everything before submitting your form to the VA.

Misconceptions

Many veterans and healthcare providers have misunderstandings about the VA 21-0960C 8 form. Here are six common misconceptions and clarifications to help clear the air.

  1. This form guarantees benefits. Many believe that simply filling out this form ensures that the veteran will receive disability benefits. In reality, the form is only a part of the evaluation process and does not guarantee approval.
  2. Filling out the form is the only step needed. Some may think that submitting the form is the only step in claiming benefits. However, additional documentation and possibly further examinations may be required for a complete evaluation.
  3. The VA pays for the completion of the form. A common myth is that the VA reimburses veterans or physicians for completing the form. This is not the case; the VA does not cover any costs incurred for the submission of this form.
  4. All headache conditions qualify for benefits. Many veterans assume that any headache condition will result in benefits. In contrast, benefits are based on severity, duration, and impact on daily life, as evaluated by the VA.
  5. A physician’s signature guarantees success. Some might believe that a doctor's approval or signature on the form guarantees the claim’s success. The VA considers multiple factors, not just the physician's endorsement, when making a decision.
  6. The form's complexity is a barrier to claiming benefits. While the form may appear complex, it is designed to gather essential information. Veterans can seek help from representatives or organizations knowledgeable about the process if needed.

Understanding these misconceptions can help navigate the process more effectively. Veterans should approach the form with clear expectations and seek assistance if they encounter challenges.

Key takeaways

Key Takeaways for VA Form 21-0960C-8

  • Understand the purpose: This form is used for veterans applying for disability benefits related to headache conditions, including migraines.
  • Be accurate and thorough: Details provided will directly impact the evaluation of the veteran's claim. Ensure all sections are filled out carefully.
  • Gather medical records: Having relevant medical history and treatment information ready can streamline the process of completing the form.
  • Physician's responsibility: The physician must certify the information submitted is accurate and complete, which adds weight to the veteran's claim.
  • Frequency of attacks: Be specific about the frequency and duration of headaches, as this information is crucial for assessing the severity of the condition.
  • Document all symptoms: Include both headache and non-headache symptoms to provide a full picture of the veteran's condition.
  • Understand your privacy rights: The form includes a Privacy Act notice, explaining how information will be used and protected. Familiarize yourself with this to understand your rights.
  • Submit on time: Ensure the completed form is submitted promptly to avoid delays in processing the veteran's benefit claim.

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