Page 15VA FORM 21-0960M-7, DEC 2017
12A. HAVE IMAGING STUDIES OF THE HANDS BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
12B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS OR RESULTS?
12C. IF ANY TEST RESULTS ARE OTHER THAN NORMAL, INDICATE RELATIONSHIP OF ABNORMAL FINDINGS TO DIAGNOSED CONDITIONS:
14. REMARKS, IF ANY:
13. REGARDLESS OF THE VETERAN'S CURRENT EMPLOYMENT STATUS, DO THE CONDITION(S) LISTED IN THE DIAGNOSIS SECTION IMPACT HIS OR HER
ABILITY TO PERFORM ANY TYPE OF OCCUPATIONAL TASK
(such as standing, walking, lifting, sitting, etc.)?
IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS
(brief summary):
NOTE: Testing listed below is not indicated for every condition. The diagnosis of degenerative arthritis (osteoarthritis) or traumatic arthritis must be confirmed by
imaging studies. Once such arthritis has been documented, even if in the past, no further imaging studies are required by VA, even if arthritis has worsened.
SECTION XII - DIAGNOSTIC TESTING
YES
IF YES, ARE THERE ABNORMAL FINDINGS?
IF YES, INDICATE FINDINGS:
DEGENERATIVE OR TRAUMATIC ARTHRITIS
OTHER. DESCRIBE:
IF YES, INDICATE HAND:
IS DEGENERATIVE OR TRAUMATIC ARTHRITIS DOCUMENTED IN MULTIPLE JOINTS OF THE SAME HAND, INCLUDING THUMB AND FINGERS?
HAND:
LEFT BOTHRIGHTHAND:
RIGHT
LEFT BOTHRIGHT
BOTHLEFT
NO
YES NO
YES NO
YES NO
SECTION XIV - REMARKS
SECTION XIII - FUNCTIONAL IMPACT
NO IF YES, DESCRIBE THE FUNCTIONAL IMPACT OF EACH CONDITION, PROVIDING ONE OR MORE EXAMPLES:YES
NOTE: Provide the impact of only the diagnosed condition(s), without consideration of the impact of other medical conditions or factors, such as age.
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, 58/VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the
Federal Register. Your obligation to respond is required to obtain or retain benefits. 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 30 minutes to review the instructions, find the information, and complete the 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.
15C. DATE SIGNED
15E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER 15F. PHYSICIAN'S ADDRESS
15B. PHYSICIAN'S PRINTED NAME
(VA Regional Office FAX No.)
15A. PHYSICIAN'S SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
NOTE: A list of VA Regional Office FAX Numbers can be found at www.vba.va.gov/disabilityexams or obtained by calling 1-800-827-1000.
SECTION XV - PHYSICIAN'S CERTIFICATION AND SIGNATURE
IMPORTANT - Physician please fax the completed form to
15D. PHYSICIAN'S PHONE AND FAX NUMBER
NOTE: VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.
PATIENT/VETERAN'S SOCIAL SECURITY NO.
