Signature
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
Date
Name of Physician (Please print)
Street Address
Tax ID Number
City
State
Zip Code
National Provider Identifier (NPI)
Email Address Phone Number
Indicate speciality, if any
For more information go to: https://www.clfamilymembers.fsc.va.gov/
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.
VA FORM
Jul 2015
10-10068b
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