OMB Number: 2900-0822
Est. Burden: 30 minutes
Expiration Date: July 31, 2018
Department of Veterans Affairs
Camp Lejeune Family Member Program Treating Physician Report
Record of Examination
Patient's Name (Last, First, Middle)
Date of Birth (MMDDYYYY)
Social Security Number
Is there any history of the following conditions/illnesses?
Yes No
These conditions/illnesses may be related to the patient's exposure to contaminated water at Camp Lejeune while living
there for at least thirty days between August 1, 1953 and December 31, 1987.
If Yes: check condition/illness below that applies. (If more than one, a separate form must be completed for each illness.)
Must provide additional information to support conclusion. *Please indicate the dates of Miscarriage and Female
Infertility. These must have occurred concurrent with exposure, prior to 1988.
Bladder cancer
Breast cancer
Esophageal cancer
Kidney cancer
Lung cancer
Multiple myeloma
Myelodysplastic syndrome
Non-Hodgkin's lymphoma
Hepatic steatosis
Renal toxicity
Neurobehavioral effects
Female infertility*
What is your specific diagnosis?
ICD-9/10 code(s)
Date of diagnosis
Date of most recent visit for this condition
Indicate the status of the condition
What treatment has been provided?
Start Date
Anticipated Treatment End Date
Start Date
Anticipated Treatment End Date
Start Date
Anticipated Treatment End Date
Other treatment
Ongoing/future treatment
Narrative: List any co-morbidities, risk factors, or other exposures that may have also contributed to this illness.
Medical records regarding the claimed condition are required in order to determine clinical eligibility.
For these three conditions (Hepatic steatosis, Renal toxicity, Neurobehavioral effects) list symptoms, diagnostic tests, etc.
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I certify the above statement to be true to the best of my abilities and acknowledge that providing false statements may
subject me to felony criminal prosecution. I affirm that I have reviewed the Release of Information signed by the patient.
Signature of Physician
Name of Physician (Please print)
Street Address
Tax ID Number
Zip Code
National Provider Identifier (NPI)
Email Address Phone Number
Indicate speciality, if any
For more information go to:
NOTE TO PHYSICIAN: Your patient is applying to the Department of Veterans Affairs (VA). VA will consider
the information you provide on this questionnaire as part of their eligibility determination for this program. This
program's eligibility criteria will be determined through the VA. Submission of this application does not
guarantee acceptance into this program.
The Paperwork Reduction Act: This information collection is in accordance with the clearance requirements of section
3507 of the Paperwork Reduction Act of 1995. Public reporting burden for this collection of information is estimated to
average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Respondents should be
aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number. The purpose of this data collection is
to determine eligibility for benefits.
Privacy Act Information: The authority for collection of the requested information on this form is 38 USC 1787. The
purpose of collecting this information is to determine your eligibility for reimbursement of health care related to conditions
determined to result from contaminated water while you resided at Camp Lejeune, North Carolina, for a period of at least
30 days. The information you provide may be verified by computer matching programs with authoritative sources such as
Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPV), Department of Defense (DoD),
Defense Enrollment Eligibility Reporting System (DEERS), Centers for Medicare & Medicaid Services (CMS) or any other
applicable authoritative source at any time. You are requested to provide your social security number as your VA record is
filed and retrieved by this number. You do not have to provide the requested information on this form but if any or all of the
requested information is not provided, it may delay or result in denial of your request for Camp Lejeune Family Member
Program benefits. Failure to furnish the requested information will have no adverse impact on any other VA benefit to
which you may be entitled. The responses you submit are considered confidential and may be disclosed outside VA only if
the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records number
23VA16. For example, information including your social security number may be disclosed to the Department of Defense,
contractors, trading partners, health care providers and other suppliers of health care services to determine your eligibility
for medical benefits and payment for services.
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