form – NABVETS

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1. SELECT THE TYPE OF CLAIM PROGRAM/PROCESS THAT APPLIES TO YOU. NOTE: Your claim will be processed as described on pages 1 through 8 unless one of the following special programs is selected. See Instruction pages 1 through 3 for definitions of the Fully Developed Claim (FDC) Program (Optional Expedited Process) or the Standard Claim Process.

FDC PROGRAM
STANDARD CLAIM PROCESS
IDES (Select this option only if you have been referred to the IDES Program by your Military Service Department)
BDD Program Claim (Select this option only if you meet the criteria for the BDD Program specified on Instruction Page 5)

2. VETERAN/SERVICEMEMBER'S NAME (First, Middle Initial, Last)

First

Middle

Last

3. SOCIAL SECURITY NUMBER (SSN)

4. HAVE YOU EVER FILED A CLAIM WITH VA?

(If "Yes," provide your file number in Item 5)

5. VA FILE NUMBER

7. SERVICE NUMBER (If applicable)

8. BDD CLAIMS ONLY: PROVIDE THE DATE OR ANTICIPATED DATE OF RELEASE FROM ACTIVE DUTY (MM-DD-YYYY)

9. TELEPHONE NUMBER (Optional) (Include Area Code)

Enter International Phone Number (If applicable)

10. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country) No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

11. EMAIL ADDRESS (Optional)

I agree to receive electronic correspondence from VA in regards to my claim.

12. IF YOU ARE CURRENTLY A VA EMPLOYEE, CHECK THE BOX (Includes Work Study/Internship) (If you are not a VA employee skip to Section II, if applicable).

Select

13A. TYPE OF ADDRESS CHANGE (Complete if applicable)

TEMPORARY
PERMANENT

13B. NEW ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

VETERAN'S SOCIAL SECURITY NO.

14A. ARE YOU CURRENTLY HOMELESS?

YES (If "Yes," complete Item 14B regarding your living situation)
NO

14B. CHECK THE BOX THAT APPLIES TO YOUR LIVING SITUATION:

LIVING IN A HOMELESS SHELTER
NOT CURRENTLY IN A SHELTERED ENVIRONMENT (e.g., living in a car or tent)
STAYING WITH ANOTHER PERSON
FLEEING CURRENT RESIDENCE

OTHER (Specify)

14C. ARE YOU CURRENTLY AT RISK OF BECOMING HOMELESS?

YES (If "Yes," complete Item 14D regarding your living situation)
NO

14D. CHECK THE BOX THAT APPLIES TO YOUR LIVING SITUATION:

HOUSING WILL BE LOST IN 30 DAYS
LEAVING PUBLICLY FUNDED SYSTEM OF CARE (e.g., homeless shelter)

OTHER (Specify)

14E. POINT OF CONTACT (Name of person VA can contact in order to get in touch with you)

14F. POINT OF CONTACT TELEPHONE NUMBER (Include Area Code)

Enter International Phone Number (If applicable)

15A. ARE YOU CLAIMING ANY CONDITIONS RELATED TO TOXIC EXPOSURES? NOTE: See Page 4 of the Instructions for further information on the evidence needed to support your claim for presumptive service connection. (You can also refer to the following websites for more information: PACT ACT (https://www.va.gov/PACT) and PUBLIC HEALTH MILITARY EXPOSURES (https://www.publichealth.va.gov/exposures/index.asp))

YES (If "Yes," complete Items 15B, 15C, 15D and 15E)
NO (If "No," skip to Item 16, Section V: Claim Information)

15B. DID YOU SERVE IN ANY OF THE FOLLOWING GULF WAR HAZARD LOCATIONS? Iraq; Kuwait; Saudi Arabia; the neutral zone between Iraq and Saudi Arabia; Bahrain; Qatar; the United Arab Emirates; Oman; Yemen; Lebanon; Somalia; Afghanistan; Israel; Egypt; Turkey; Syria; Jordan; Djibouti; Uzbekistan; the Gulf of Aden; the Gulf of Oman; the Persian Gulf; the Arabian Sea; and the Red Sea

FROM:

TO:

15C. DID YOU SERVE IN ANY OF THE FOLLOWING HERBICIDE (e.g., Agent Orange) LOCATIONS? Republic of Vietnam to include the 12 nautical mile territorial waters; Thailand at any United States or Royal Thai base; Laos; Cambodia at Mimot or Krek; Kampong Cham Province; Guam or American Samoa; or in the territorial waters thereof; Johnston Atoll or a ship that called at Johnston Atoll; Korean demilitarized zone; aboard (to include repeated operations and maintenance with) a C-123 aircraft known to have been used to spray an herbicide agent (during service in the Air Force and Air Force Reserves).

Please list other location(s) where you served, if not listed above:

FROM:

TO:

15D. HAVE YOU BEEN EXPOSED TO ANY OF THE FOLLOWING? (Check all that apply)

OTHER (Specify)

FROM:

TO:

15E. IF YOU WERE EXPOSED MULTIPLE TIMES, PLEASE PROVIDE ALL ADDITIONAL DATES AND LOCATIONS OF POTENTIAL EXPOSURE

VETERAN'S SOCIAL SECURITY NO.

A. ENTER THE DISABILITY TREATED AND NAME/LOCATION OF THE TREATMENT FACILITY

C. CHECK THE BOX IF YOU DO NOT HAVE DATE(S) OF TREATMENT

Don't have date
Don't have date
Don't have date

VETERAN'S SOCIAL SECURITY NO

18A. DID YOU SERVE UNDER ANOTHER NAME?

YES (If "Yes," complete Item 18B)
NO (If "No," skip to Item 19A)

18B. LIST THE OTHER NAME(S) YOU SERVED UNDER

19B. COMPONENT

ACTIVE
RESERVES
NATIONAL GUARD

20B. PLACE OF LAST OR ANTICIPATED SEPARATION

20C. DID YOU SERVE IN A COMBAT ZONE SINCE 9-11-2001?

20D. ADDITIONAL PERIODS OF SERVICE (Indicate enlistment and discharge date(s), if applicable)

21A. ARE YOU CURRENTLY SERVING OR HAVE YOU EVER SERVED IN THE RESERVES OR NATIONAL GUARD?

YES (If "Yes," complete Items 21B through 21F)
NO (If "No," skip to Item 22A)

21B. COMPONENT

NATIONAL GUARD
RESERVES

21D. CURRENT OR LAST ASSIGNED NAME AND ADDRESS OF UNIT:

21E. CURRENT OR ASSIGNED PHONE NUMBER OF UNIT (Include Area Code)

21F. ARE YOU CURRENTLY RECEIVING INACTIVE DUTY TRAINING PAY?

22A. ARE YOU CURRENTLY ACTIVATED ON FEDERAL ORDERS WITHIN THE NATIONAL GUARD OR RESERVES?

YES (If "Yes," complete Items 22B & 22C)
NO

23A. HAVE YOU EVER BEEN A PRISONER OF WAR?

YES (If "Yes," complete Item 23B)
NO

24A. ARE YOU RECEIVING MILITARY RETIRED PAY?

YES (If "Yes," complete Items 24C and 24D)
NO

24B. WILL YOU RECEIVE MILITARY RETIRED PAY IN THE FUTURE?

YES (If "Yes," explain below (e.g. future Reserve/National Guard retirement, pending MEB/PEB and also complete Items 24C and 24D)
NO

24D. MONTHLY AMOUNT

25. RETIRED STATUS

RETIRED
PERMANENT DISABILITY RETIRED LIST
TEMPORARY DISABILITY RETIRED LIST

IMPORTANT: VA COMPENSATION PAY IS NON-TAXABLE. THEREFORE, VA COMPENSATION PAY MAY BE THE GREATER BENEFIT

26. Do NOT pay me VA compensation. I do NOT want to receive VA compensation in lieu of retired pay.

VETERAN'S SOCIAL SECURITY NO

27A. HAVE YOU EVER RECEIVED SEPARATION PAY, DISABILITY SEVERANCE PAY, OR ANY OTHER LUMP SUM PAYMENT FROM YOUR BRANCH OF SERVICE?

YES (If "Yes," complete Items 27B through 27D)
NO

27D. AMOUNT RECEIVED (Provide pre-tax amount)

IMPORTANT: VA COMPENSATION PAY IS NON-TAXABLE. THEREFORE VA COMPENSATION PAY MAY BE THE GREATER BENEFIT.

28. Do NOT pay me VA compensation. I do NOT want to receive VA compensation in lieu of training pay.

29. I CERTIFY THAT I DO NOT HAVE AN ACCOUNT WITH A FINANCIAL INSTITUTION OR CERTIFIED PAYMENT AGENT

(If you check this box skip to Section IX)

30. ACCOUNT NUMBER (Check only one box below and provide the account number) Account No.:

31. NAME OF FINANCIAL INSTITUTION (Provide the name of the bank where you want your direct deposit)

Select account

CHECKING
SAVINGS

32. ROUTING OR TRANSIT NUMBER (The first nine numbers located at the bottom left of your check)

34B. PRINTED NAME AND ADDRESS OF WITNESS

35B. PRINTED NAME AND ADDRESS OF WITNESS

VETERAN'S SOCIAL SECURITY NO.

36B. DATE SIGNED (MM-DD-YYYY)

37B. DATE SIGNED (MM-DD-YYYY)

VETERAN'S SOCIAL SECURITY NO

CURRENT DISABILITY(IES)

IF DUE TO EXPOSURE, EVENT, OR INJURY, PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits)

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY

APPROXIMATE DATE DISABILITY(IES) BEGAN OR WORSENED

1. NAME OF VETERAN (First, Middle, Last)

First

Middle

Last

2. VETERAN'S SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

4. VETERAN'S ADDRESS (Number, street or rural route, City or P.O., State and ZIP Code)

5. TELEPHONE NUMBER(S)

A. DAYTIME (Include Area Code)

B. EVENING

B. EVENING (Include Area Code)

6. E-MAIL ADDRESS (If applicable)

7. I WOULD LIKE TO FILE A CLAIM FOR: (Check all that apply)

INCREASED EVALUATION OF THE DISABILITY(IES) FOR WHICH I AM ALREADY SERVICE CONNECTED (Provide the name of the disability(ies))
SERVICE CONNECTION FOR NEW DISABILITY(IES) (List your new disability(ies))
REOPENING OF PREVIOUSLY DENIED DISABILITY(IES) (List your previously denied disability(ies))
DISABILITY(IES) SECONDARY TO MY EXISTING SERVICE CONNECTED DISABILITY(IES) (Provide the name of the disability(ies) and your service connected condition(s))

8A. NAME AND LOCATION OF VA MEDICAL CENTER THAT HAS MY RELEVANT TREATMENT RECORDS

8B. NAME AND ADDRESS OF MILITARY FACILITY THAT HAS MY RELEVANT TREATMENT RECORDS

8C. DO YOU HAVE PRIVATE TREATMENT RECORDS?

(If "Yes," please attach the treatment records to this form. If you would like to have VA request your private treatment records, please attach a VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs, for each private treatment provider. The form is available at www.va.gov/vaforms.)

9. I WOULD LIKE TO FILE A CLAIM FOR OTHER VA BENEFITS (Check appropriate box)

AID AND ATTENDANCE
AUTOMOBILE ALLOWANCE
OTHER (Specify benefit)

OTHER (Specify benefit)

10. I WOULD LIKE TO FILE A CLAIM FOR ADDITIONAL BENEFITS BECAUSE MY SPOUSE IS SERIOUSLY DISABLED

(Please provide spouse's name and social security number in Items 10A & 10B)

A. SPOUSE'S NAME

B. SPOUSE'S SOCIAL SECURITY NO

1. VETERAN'S NAME (First, Middle Initial, Last)

First

Middle

Last

2. VETERAN'S SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

5. CLAIMANT'S NAME (First, Middle Initial, Last)

First

Middle

Last

6. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country) No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

7. TELEPHONE NUMBER (Include Area Code)

8. E-MAIL ADDRESS (Optional)

9. WOULD YOU LIKE TO RECEIVE A TELEPHONE CALL OR E-MAIL FROM A REPRESENTATIVE AT YOUR LOCAL REGIONAL OFFICE REGARDING YOUR NOD?

(If you answered "Yes," VA will make up to two attempts to call you between 8:00 a.m. and 4:30 p.m. local time at the telephone number and time period you select below. Please select up to two time periods you are available to receive a phone call.)

8:00 a.m. - 10:00 a.m.
10:00 a.m. - 12:30 p.m.
12:30 p.m. - 2:00 p.m.
2:00 p.m. - 4:30 p.m.

Phone number I can be reached at the above checked time:

10. SELECT ONE OF THE APPEALS PROCESSING METHODS BELOW (See Specific Instructions, Page 2, Section IV for additional information)

Decision Review Officer (DRO) Review Process
Traditional Appellate Review Process

VETERAN'S SSN

11. NOTIFICATION/DECISION LETTER DATE

Service Connection
Effective Date of Award
Evaluation of Disability
Other (Please specify below)

13A. IN THE SPACE BELOW, OR ON A SEPARATE PAGE, PLEASE EXPLAIN WHY YOU FEEL WE INCORRECTLY DECIDED YOUR CLAIM, AND LIST ANY DISAGREEMENT(S) NOT COVERED ABOVE:

13B. DID YOU ATTACH ADDITIONAL PAGES TO THIS NOD?

YES
NO (If so, how many?)

1. VETERAN'S NAME (First, Middle Initial, Last)

First

Middle

Last

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER (If applicable)

5. VETERAN'S SERVICE NUMBER (If applicable)

6. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)

No. & Stree

Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

7. TELEPHONE NUMBER (Include Area Code)

Enter International Phone Number (If applicable)

8. E-MAIL ADDRESS (Optional)

I agree to receive electronic correspondence from VA in regards to my claim.

I agree

9. PATIENT'S NAME (First, Middle Initial, Last)

First

Middle

Last

10. SOCIAL SECURITY NUMBER

11. VA FILE NUMBER (If applicable)

VETERAN'S SOCIAL SECURITY NO.

12. IF MY CONSENT TO THIS INFORMATION IS LIMITED, THE LIMITATION IS WRITTEN HERE (If this space is left blank, there is no limitation to records):

14. DATE SIGNED (MM/DD/YYYY) (Required)

15. PRINTED NAME OF PERSON SIGNING (First, Middle Initial, Last)

First

Middle

Last

16. RELATIONSHIP TO VETERAN/CLAIMANT (If other than self, please provide full name, title, organization, street, city, State, and ZIP code. All court appointments must include docket number, county, and State)

1. VETERAN'S NAME (First, Middle Initial, Last)

First

Middle

Last

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

5. VETERAN'S SERVICE NUMBER (If applicable)

6. PATIENT'S NAME (First, Middle Initial, Last)

First

Middle

Last

7. SOCIAL SECURITY NUMBER

8. VA FILE NUMBER

9A. PROVIDER OR FACILITY NAME

9B. CONDITIONS YOU ARE BEING TREATED FOR

FROM

9D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

10A. PROVIDER OR FACILITY NAME

10B. CONDITIONS YOU ARE BEING TREATED FOR

From:

To:

10D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

VETERAN'S SOCIAL SECURITY NO

11A. PROVIDER OR FACILITY NAME

11B. CONDITIONS YOU ARE BEING TREATED FOR

From:

To:

11D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

12A. PROVIDER OR FACILITY NAME

12B. CONDITIONS YOU ARE BEING TREATED FOR

From:

To:

12D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

13A. PROVIDER OR FACILITY NAME

13B. CONDITIONS YOU ARE BEING TREATED FOR

From:

To:

13D. PROVIDER/FACILITY STREET ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

1. VETERAN/BENEFICIARY'S NAME (First, Middle Initial, Last)

First

Middle

Last

2. SOCIAL SECURITY NUMBER

4. VETERAN'S SERVICE NUMBER (If applicable)

3. VA FILE NUMBER (If applicable)

6. CLAIMANT'S NAME (First, Middle Initial, Last)

First

Middle

Last

7. CLAIMANT'S SOCIAL SECURITY NUMBER

8. RELATIONSHIP OF CLAIMANT TO VETERAN

SELF
SPOUSE
PARENT
CHILD

10. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)

No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

11. TELEPHONE NUMBER (Optional) (Include Area Code)

Enter International Phone Number (If applicable)

EMAIL ADDRESS (Optional)

I agree to receive electronic correspondence from VA in regards to my claim

I agree

13. SELECT ONE OF THE FOLLOWING BENEFITS (Choose one)

Special Monthly Compensation (SMC) - Veterans and surviving spouses or parents who are eligible to receive VA compensation due to a service-related disability or death and require aid and attendance of another person to perform personal functions required in everyday living such as bathing, feeding, dressing, attending to the wants of nature, adjusting prosthetic devices, or protecting oneself from the hazards of the daily environment may be eligible for Special Monthly Compensation. A veteran or a deceased veteran's surviving spouse may also be eligible for Special Monthly Compensation based on being housebound (substantially confined to the immediate premises because of permanent disability). For a veteran, the disability causing the need for aid and attendance or housebound status must be related to service. These benefits are paid in addition to monthly compensation or Dependency Indemnity Compensation (DIC). They are not paid without eligibility to compensation.
Special Monthly Pension (SMP) - Veterans and survivors who are eligible for Veteran's Pension and/or Survivors benefits and require the aid and attendance of another person in order to perform personal functions required in everyday living, such as bathing, feeding, dressing, attending to the wants of nature, adjusting prosthetic devices, or protecting them from the hazards of their daily environment, or are housebound (substantially confined to their immediate premises because of permanent disability), may be eligible for Special Monthly Pension (SMP). This benefit is an increased monthly amount paid to a veteran or survivor who is eligible for Veterans Pension or Survivors benefits.

VETERAN'S SOCIAL SECURITY NUMBER

14A. IS THE CLAIMANT HOSPITALIZED?

YES (If "YES," complete Items 14B, 14C & 14D)
NO (If "NO," skip to Section V)

14C. NAME OF HOSPITAL

14D. ADDRESS OF HOSPITAL

17. PROVIDE COMPLETE DIAGNOSIS WITH MOST SIGNIFICANT SYMPTOMS FOR EACH CONDITION (Diagnosis needs to equate to the level of assistance described in Items 26 through 37) (Describe below)

18. WHAT DISABILITY(IES) ARE CONSIDERED PERMANENT AND TOTALLY DISABLING? (Describe below) A

18. WHAT DISABILITY(IES) ARE CONSIDERED PERMANENT AND TOTALLY DISABLING? (Describe below) B

18. WHAT DISABILITY(IES) ARE CONSIDERED PERMANENT AND TOTALLY DISABLING? (Describe below) C

18. WHAT DISABILITY(IES) ARE CONSIDERED PERMANENT AND TOTALLY DISABLING? (Describe below) D

18. WHAT DISABILITY(IES) ARE CONSIDERED PERMANENT AND TOTALLY DISABLING? (Describe below) E

18. WHAT DISABILITY(IES) ARE CONSIDERED PERMANENT AND TOTALLY DISABLING? (Describe below) F

19A. AGE

19B. WEIGHT

ACTUAL LBS.

19B. WEIGHT

ESTIMATED LBS

19C. HEIGHT (FEET)

19C. HEIGHT (INCHES)

20. NUTRITION

21. GAIT

22. BLOOD PRESSURE

23. PULSE RATE

24. RESPIRATORY RATE

25. WHAT DISABILITIES RESTRICT THE LISTED ACTIVITIES/FUNCTIONS?

VETERAN'S SOCIAL SECURITY NUMBER

26. IF THE PATIENT IS CONFINED TO BED, INDICATE THE NUMBER OF HOURS IN BED

From 9 PM to 9 AM

26. IF THE PATIENT IS CONFINED TO BED, INDICATE THE NUMBER OF HOURS IN BED

From 9 AM to 9 PM:

27. DOES THE PATIENT REQUIRE ASSISTANCE WITH ANY OF THE FOLLOWING ACTIVITIES? (Select ALL that apply)

BATHING/SHOWERING
EATING OR SELF-FEEDING
DRESSING
AMBULATING WITHIN THE HOME OR LIVING AREA
TENDING TO HYGIENE NEEDS
TRANSFERRING IN OR OUT OF BED/CHAIR
TOILETING
MEDICATION MANAGEMENT
ADDITIONAL ACTIVITIES (i.e., housekeeping, laundering, meal preparation, etc.) (Specify additional activity below)

ADDITIONAL ACTIVITIES (i.e., housekeeping, laundering, meal preparation, etc.) (Specify additional activity below)

28A. IS THE PATIENT LEGALLY BLIND? (If "Yes," provide explanation)

28B. CORRECTED VISION

LEFT EYE

28B. CORRECTED VISION

RIGHT EYE

29. DOES THE PATIENT REQUIRE NURSING HOME CARE? (If "Yes," provide explanation)

30. IN YOUR JUDGMENT, DOES THE PATIENT HAVE THE MENTAL CAPACITY TO MANAGE THEIR BENEFIT PAYMENTS, OR ARE THEY ABLE TO DIRECT SOMEONE TO DO SO?

(If "NO," provide the disability(ies) that prevent them from performing this function and any rationale to support your conclusion in the space provided)

31. WHAT IS THE POSTURE AND GENERAL APPEARANCE OF THE PATIENT? (Describe)

32. DESCRIBE RESTRICTIONS OF EACH UPPER EXTREMITY WITH PARTICULAR REFERANCE TO GRIP, FINE MOVEMENTS, AND ABILITY TO FEED THEMSELVES, TO BUTTON CLOTHING, SHAVE AND ATTEND TO THE NEEDS OF NATURE

33. DESCRIBE RESTRICTIONS OF EACH LOWER EXTREMITY WITH PARTICULAR REFERANCE TO THE EXTENT OF LIMITATION OF MOTION, ATROPHY, AND CONTRACTURES OR OTHER INTERFERENCE. (NOTE: If indicated, comment specifically on weight bearing, balance and propulsion of each lower extremity)

34. DESCRIBE RESTRICTION OF SPINE, TRUNK, AND NECK

VETERAN'S SOCIAL SECURITY NUMBER

35. DESCRIBE ALL OTHER PATHOLOGY INCLUDING THE LOSS OF BOWEL OR BLADDER CONTROL OR THE EFFECTS OF ADVANCING AGE; SUCH AS DIZZINESS, LOSS OF MEMORY OR POOR BALANCE, THAT AFFECTS PATIENT'S ABILITY TO PERFORM SELF-CARE, OR IF HOSPITALIZED, BEYOND THE WARD OR CLINICAL AREA

36. HOW OFTEN PER DAY OR WEEK AND UNDER WHAT CIRCUMSTANCES (to include the level of assistance required) IS THE PATIENT ABLE TO LEAVE THE HOME OR IMMEDIATE PREMISES (Describe)

37. ARE AIDS SUCH AS CANES, BRACES, CRUTCHES, OR THE ASSISTANCE OF ANOTHER PERSON REQUIRED FOR LOCOMOTION?

OTHER (Specify distance)

38. PRINTED NAME OF EXAMINER

39. TITLE OF EXAMINER

42. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER OF EXAMINER

43. NAME OF MEDICAL FACILITY

44. ADDRESS OF MEDICAL FACILITY (Number and street or rural route, city, state, ZIP Code and Country)

45. TELEPHONE NUMBER OF MEDICAL FACILITY (Include Area Code)

Enter International Phone Number (If applicable)