DEPARTMENT OF VETERANS AFFAIRS Medical Center 921 Northeast 13th Street Oklahoma City, OK /136

Transcription

1 DEPARTMENT OF VETERANS AFFAIRS Medical Center 921 Northeast 13th Street Oklahoma City, OK /136 Dear Veteran: In mid-1978, the Department of Veteran Affairs set up a Registry of Vietnam Veterans due to potential health concerns following exposure to chemical herbicides. As part of the Registry process, a medical examination is offered at many VA health care facilities. The examination provides the participating veteran with an opportunity to receive a complete health evaluation and answers to questions concerning the current state of knowledge regarding the possible relationship between herbicide exposure and subsequent health problems. No special Agent Orange test are offered since there is no test to show if a veteran s medical problem was caused by Agent Orange or other herbicides used in Vietnam. Please complete the attached questionnaire and the enclosed EZ Application. Please return the completed forms along with a copy of your DD-214(s) or other discharge papers to the! VA MEDICAL CENTER! 921 NE 13TH STREET! OKLAHOMA CITY, OK 73104! ATTN:! 136/SHELIA RAY Your application will be processed and you will be scheduled for a medical evaluation at this Medical Center. If you have any questions, please call me at (405) This initial evaluation will be at no cost to you. Whether you are entitled to further cost-free treatment or will be responsible for partial co-payment will be determined by your income and other factors unless the VA Regional Office determines that your health problems are serviced connected. Please note that this examination does not constitute a formal claim for VA benefits. If you wish to file a claim for service connection of a medical disability related to your military service, please contact a Veterans Benefit Counselor at ( ) or a Veteran s Service Organization. Sincerely, SHELIA RAY Veterans Environmental Coordinator

2 AGENT ORANGE REGISTRY Last, First, Middle Full Name: SSN: Date of Birth: Permanent Mailing Address: City/State/Zip: County: Telephone Number: ( ) Sex: Male Female Marital Status: Married Divorced Separated Widowed Single Never Married Race: American Indian Asian Black or African American Native Hawaiian or other Pacific Islander White Hispanic or Latino What Branch of Service: Army Navy Air Force USMC Active Duty in: Vietnam Yes No From to Korea ( ) Yes No From to Other Yes No From to If in Vietnam, place an X by the CORPS you serve? (see attached Map of Vietnam) I CORPS II CORPS III CORPS IV CORPS Sea Duty If other please specify: List Military Units in which you served. Please specify complete unabbreviated Title, Company, Battalion, Etc.

3 Please indicate your exposure to Agent Orange 1=Definitely Yes 2=Unsure 3=Not Exposed I was involved in handling or spraying Agent Orange I was not directly sprayed with Agent Orange, but in a recently sprayed area I was exposed to herbicides other than Agent Orange I was directly sprayed with Agent Orange I ate food or drink that could have been contaminated with Agent Orange Please answer the following: How Many Biological Children do you have? How many were born before Vietnam? Did any of the children born before Vietnam show evidence of a birth defect? Yes or No If yes, what was the mother s age at the time of conception? If yes, please describe the defect How many were born after Vietnam? Did any of the children born after Vietnam show evidence of a birth defect? Yes or No If yes, what was the mother s age at the time of conception? If yes, please describe the defect

4 Health Conditions Recognized for Presumptive Service-Connection Please mark with an X if you have been given any of the following diagnoses and if present please provide the date the condition was diagnosed: Acute and Subacute Peripheral Neuropathy: Date Diagnosed A nervous system condition that causes numbness, tingling, and motor weakness. Under VA s rating regulations, it must be at least 10% disabling within 1 year of exposure to herbicides and resolve within 2 years after the date it began. AL Amyloidosis: Date Diagnosed A rare disease caused when an abnormal protein, amyloid, enters tissues or organs. Chloracne (or Similar Acneform Disease): Date Diagnosed A skin condition that occurssoon after exposure to chemicals and looks like common forms of acne seen in teenagers. Under VA s rating regulations, chloracne (or other acneform disease similar to chloracne) must be at least 10% disabling within 1 year of exposure to herbicides. Chronic B-cell Leukemias: Date Diagnosed A type of cancer which affects white blood cells. Diabetes Melliyus (Typs 2): Date Diagnosed A disease characterized by high blood sugar levels resulting from the body s inability to respond properly to the hormone insulin. Hodgkin s Disease: Date Diagnosed A malignant lymphoma (cancer) characterized by progressive enlargement of the lymph nodes, liver, and spleen, and by progressive anemia. Ischemic Heart Disease: Date Diagnosed: A disease characterized by a reduced supply of blood to the heart, that leads to chest pain. Multiple Myeloma: Date Diagnosed A cancer of plasma cells, a type of white blood cell in bone marrow. Non-Hodgkin s Lymphoma: Date Diagnosed A group of cancers that affect the lymph glands and other lymphatic tissue.

5 Parkinson s Disease: Date Diagnosed A progressive disorder of the nervous system that affects muscle movement. Porphyria Cutanea Tarda: Date Diagnosed A disorder characterized by liver dysfunction and by thinning and blistering of the skin in sun-exposed areas. Under VA s rating regulations, it must be at least 10% disabling within 1 year of exposure to herbicides. Prostate Cancer: Date Diagnosed Cancer of the prostate; one of the most common cancers among men. Respiratory Cancer: Date Diagnosed Cancers of the lung, larynx, trachea, and bronchus. Soft Tissue Sarcoma (other than Osteosarcoma, Chondrosarcoma, Kaposi s sarcoma, or Mesothelioma): Date Diagnosed A group of different types of cancers in body tissues such as muscle, fat, blood and lymph vessels, and connective tissues. ********************************************************************** PLEASE TE: IF YOU MARKED TO ANY OF THE ABOVE DIAGSES, PLEASE ATTEMPT TO BRING RECORDSM THAT DOCUMENT THE DATE OF THE DIAGSIS. FOR EXAMPLE: LAB EVALUATION, PATHOLOGY REPORT OF TE FROM THE DIAGSING PROVIDER. ********************************************************************** PLEASE TE: If you have checked yes to any of the above conditions you may be eligible for disability compensation from the VA. Contact a VA Veteran Service Representative at the nearest VA Regional Office or health care facility to talk with a counselor and apply for disability compensation as soon as possible. The national number is To start a disability claim online, go to You also can get information about disability compensation from VA s Special Issues Helpline at *****************************************************************************

6 MEDICAL HISTORY Are you allergic to any medications Yes No If you have checked yes, please list the medication that you are allergic to and the reaction the medication caused. List any prescribed medication you are taking. (You do not have to list the medications if you receive them from the VA pharmacy) Medication Dose Frequency Please list all previous hospitalizations including the date and the reason. Where Hospitalized Reason Hospitalized Date Hospitalized Please provide a list of your current diagnoses and if possible the date these were diagnosed. (for example: Cancer, high blood pressure, diabetes, heart disease etc.)

7 Please list the name of your treating providers: If applicable Primary Care Oncologist Urologist Cardiologist Please provide a listof any symptoms/problems you have been experiencing since you have returned from combat. Are you currently employed? or If you are employed, what is your current occupation? If you are not employed please explain Do you currently smoke? or If yes, how many packs per day do you smoke? How many years total have you smoked? Did you ever smoke? or When did you quit smoking? How many years did you smoke before quitting? How many packs per day did you average before quitting? Do you use any other tobacco products? or What do you use? If you use smokeless tobacco how many years total have you used? Do you use any recreational drugs? or Do you have a history of recreational drug use? or Do you consume alchol products? or How often do you consume alcohol products? How much alcohol do you consume each time?

8 I CORPS II CORPS III CORPS IV CORPS

9 PROVINCES AND CITIES IN SOUTH VIETNAM AND MILITARY SITES l CORPS A Shau, An Hoa, Binh Hoa, Cam Lo, Camp Carrol, Camp Eagle, Camp Esso, Camp Evans, Camp Henderson, Chu Lai, Con Thien, Da Nang, China Beach, Dong Ha, Due Pho, U Bronco, Firebase Jack, Firebase Rldcassan, Firebase West, Hill 63, Hill 69, Hoi An, Hue, Khe Sanh, Firebase Smith, Lan Co Bridge, LZ Baldy, LZ Dogpatch, Hill 327, LZ Geronimo, LZ Jane, Firebase Barbara, LZ Langley, Firebase Shepard, UProfess, Hill 55, LZ Roc.kcrusher,Hill 85, LZ Rockpile, LZ Ross, LZ Sandra, LZ Snapper, Firebase Leather, Marble Hill 59, Phu Bai, Phu Loc, LZ Tomahawk, Thua Them, Quang Nai, Quang Nam, Quang Tin, Quang Ngai, Quang Tri, LZ Nancy. II CORPS An Khe, Camp Radcliff, An Lao, LZ Laramie, Ban Me Thuot, Ben Het, Binh Dinh, Binh Thuan, Bon Song, LZ Two Bits, Bre Nbi, Cam Ranh Bay, Camp Granite, Che Reo, Da Lat, DaleTo, Dar Lac, Dak To Firebase Pony, Kontum, Khanh Hoa, Lan Dong, LZ Dog, LZ English,LZ Oasis,U Putter, Firebase Bird, LZ Uplift, Nba Trang, Ninh ~Pharn Rang, Pbari Thiet, Plei Ho, SF Camp, Plei Jerang, Pleilcu, Phu Bon, Phu Cat, Phu Yen LZ Hammond, Qui Nhon, Quang Due, Song Cau, Tuy An, Tuyon Due, Tuy Hoa III CORPS An Loc, Ben Cat, Bien Hoa, Binh Tuy, Binh Long, Claolon, Cu Chi, Dau Tieng (Michelin), Dien Due, Dinh Duong, Firebase Elaine, Due Hoa, FirebaseDi An, Firebase Frenzel, Firebase Jewel, LZ Snuffy, Firebase Mace, Gia Dinh, Hay Hghai, Katutn, Lai Khe, Loc Ninh, Long An, Long Kbanh, Long Binh, Firebase Concord, LZ Bearcat, LZ Fish Nook, LZ Schofield, Nba Be (Navy Base), Nui Ba Den, Firebase Caroline, Phouc Vinh, Phuoe Tuy Phou Long, Phu Cuong, Phu Loi, Qua Viet, Quan Loi, Saigon, Song Be, Tan Son Nhut, Tay ninh, Trang Bang, Vo Dat, Firebase Nancy, Vung Tau, Xuan Loc IV CORPS An Giang, An Xuyen, Ba Xuyen, Ben Luc, Ben Tre, Can Tho, Cao Lanh, Can Mau, Chunong Thion, Dong Tam, Due Liou, Dinh Tuong, Firebase Grand Can, Firebase Moore, Go Cong, Ham Long, Kion Giang, Kien Hoa, Kien Phong, Mekong Delta, Moe Hoa, My Tho, Nam Can, Phnom, Phong Dinh, Phy Quoe, Raeh Gia, Seafioat, Soc Trang, Tan An, Tieu con, Tra Vinh, Vinh Binh, Vinh Loi, Vinh Long

10 OMB Approved No Estimated Burden Avg. 30 min. APPLICATION FOR HEALTH BENEFITS SECTION I - GENERAL INFORMATION Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years, for concealing a material fact or making a materially false statement. (See 18 U.S.C. 1001) 1. VETERAN'S NAME (Last, First, Middle Name) 2. MOTHER'S MAIDEN NAME 3. GENDER MALE FEMALE 4. ARE YOU SPANISH, HISPANIC, OR LATI? 5. WHAT IS YOUR RACE? (You may check more than one. Information is required for statistical purposes only.) AMERICAN INDIAN OR ALASKA NATIVE ASIAN WHITE BLACK OR AFRICAN AMERICAN NATIVE AMERICAN OR OTHER PACIFIC ISLANDER 6. SOCIAL SECURITY NUMBER 7. DATE OF BIRTH (mm/dd/yyyy) 7A. PLACE OF BIRTH (City and State) 8. PERMANENT ADDRESS (Street) 8A. CITY 8B. STATE 8C. ZIP CODE 8D. COUNTY 8E. HOME TELEPHONE NUMBER (Include area code) 8F. MOBILE TELEPHONE NUMBER (Include area code) 8G. ADDRESS ( ) 9. CURRENT MARTIAL STATUS MARRIED NEVER MARRIED SEPARATED WIDOWED DIVORCED 10. I AM ENROLLING TO OBTAIN MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE CARE ACT 11. WHICH VA MEDICAL CENTER OR OUTPATIENT CLINIC DO YOU PREFER? (for listing of facilities visit WOULD YOU LIKE FOR VA TO CONTACT YOU TO SCHEDULE YOUR FIRST APPOINTMENT? SECTION II - MILITARY SERVICE INFORMATION 1. LAST BRANCH OF SERVICE 1A. LAST ENTRY DATE 1B. LAST DISCHARGE DATE 1C. DISCHARGE TYPE 2. MILITARY HISTORY (Check yes or no) A. ARE YOU A PURPLE HEART AWARD RECIPIENT? E. DID YOU SERVE IN SW ASIA DURING THE GULF WAR BETWEEN AUGUST 2, 1990 AND VEMBER 11, 1998? B. ARE YOU A FORMER PRISONER OF WAR? C. DID YOU SERVE IN A COMBAT THEATER OF OPERATIONS AFTER 11/11/1998? D. WERE YOU DISCHARGED OR RETIRED FROM MILITARY FOR A DISABILITY INCURRED IN THE LINE OF DUTY? F. DID YOU SERVE IN VIETNAM BETWEEN JANUARY 9, 1962 AND MAY 7, 1975? G. WERE YOU EXPOSED TO RADIATION WHILE IN THE MILITARY? H. DID YOU RECEIVE SE AND THROAT RADIUM TREATMENTS WHILE IN THE MILITARY? I. DID YOU SERVE ON ACTIVE DUTY AT LEAST 30 DAYS AT CAMP LEJEUNE FROM AUGUST 1, 1953 THROUGH DECEMBER 31, 1987? SECTION III - INSURANCE INFORMATION (Use a separate sheet for additional information) 1. ENTER YOUR HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER (include coverage through spouse or other person) 2. NAME OF POLICY HOLDER 3. POLICY NUMBER 4. GROUP CODE 5. ARE YOU ELIGIBLE FOR MEDICAID? 6. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A? 6A. EFFECTIVE DATE (mm/dd/yyyy) VA FORM MAR EZ PREVIOUS EDITIONS OF THIS FORM ARE T TO BE USED PAGE 1

11 APPLICATION FOR HEALTH BENEFITS, Continued VETERAN'S NAME (Last, First, Middle) SOCIAL SECURITY NUMBER SECTION IV - DEPENDENT INFORMATION (Use a separate sheet for additional dependents) 1. SPOUSE'S NAME (Last, First, Middle Name) 2. CHILD'S NAME (Last, First, Middle Name) 1A. SPOUSE'S SOCIAL SECURITY NUMBER 2A. CHILD'S DATE OF BIRTH (mm/dd/yyyy) 2B. CHILD'S SOCIAL SECURITY NUMBER 1B. SPOUSE'S DATE OF BIRTH (mm/dd/yyyy) 2C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy) 1C. DATE OF MARRIAGE (mm/dd/yyyy) 2D. CHILD'S RELATIONSHIP TO YOU (Check one) SON DAUGHTER STEPSON STEPDAUGHTER 1D. SPOUSE'S ADDRESS AND TELEPHONE NUMBER (Street, City, State, ZIP - if different from Veteran's) 2E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18? 2F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL LAST CALENDAR YEAR? 3. IF YOUR SPOUSE OR DEPENDENT CHILD DID T LIVE WITH YOU LAST YEAR, DID YOU PROVIDE SUPPORT? 2G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition, books, materials) SECTION V - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN (Use a separate sheet for additional dependents) VETERAN SPOUSE CHILD 1 1. GROSS ANNUAL INCOME FROM EMPLOYMENT (wages, bonuses, tips, etc.) EXCLUDING INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS 2. NET INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS 3. LIST OTHER INCOME AMOUNTS (e.g., Social Security, compensation, pension interest, dividends) EXCLUDING WELFARE. SECTION VI - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES 1. TOTAL N-REIMBURSED MEDICAL EXPENSES PAID BY YOU OR YOUR SPOUSE (e.g., payments for doctors, dentists, medications, Medicare, health insurance, hospital and nursing home) VA will calculate a deductible and the net medical expenses you may claim. 2. AMOUNT YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL EXPENSES (INCLUDING PREPAID BURIAL EXPENSES) FOR YOUR DECEASED SPOUSE OR DEPENDENT CHILD (Also enter spouse or child's information in Section VI.) 3. AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSES (e.g., tuition, books, fees, materials) DO T LIST YOUR DEPENDENTS' EDUCATIONAL EXPENSES. SECTION VII - CONSENT TO COPAYS AND TO RECEIVE COMMUNICATIONS By submitting this application you are agreeing to pay the applicable VA copays for treatment or services of your NSC conditions as required by law. You also agree to receive communications from VA to your supplied or mobile number. ASSIGNMENT OF BENEFITS I understand that pursuant to 38 U.S.C. Section 1729 and 42 U.S.C. 2651, the Department of Veterans Affairs (VA) is authorized to recover or collect from my health plan (HP) or any other legally responsible third party for the reasonable charges of nonservice-connected VA medical care or services furnished or provided to me. I hereby authorize payment directly to VA from any HP under which I am covered (including coverage provided under my spouse's HP) that is responsible for payment of the charges for my medical care, including benefits otherwise payable to me or my spouse. Furthermore, I hereby assign to the VA any claim I may have against any person or entity who is or may be legally responsible for the payment of the cost of medical services provided to me by the VA. I understand that this assignment shall not limit or prejudice my right to recover for my own benefit any amount in excess of the cost of medical services provided to me by the VA or any other amount to which I may be entitled. I hereby appoint the Attorney General of the United States and the Secretary of Veterans' Affairs and their designees as my Attorneys-in-fact to take all necessary and appropriate actions in order to recover and receive all or part of the amount herein assigned. I hereby authorize the VA to disclose, to my attorney and to any third party or administrative agency who may be responsible for payment of the cost of medical services provided to me, information from my medical records as necessary to verify my claim. Further, I hereby authorize any such third party or administrative agency to disclose to the VA any information regarding my claim. ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS WHICH DEFINE WHO CAN SIGN ON BEHALF OF THE VETERAN. SIGNATURE OF APPLICANT DATE VA FORM MAR EZ PAGE 2

12 TO: DEPARTMENT OF VETERANS AFFAIRS (Print or type name and address of health care facility) REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL RECORDS OR HEALTH INFORMATION PATIENT NAME (Last, First, Middle Initial) OMB Number: Estimated Burden: 2 minutes Privacy Act and Paperwork Reduction Act Information: The execution of this form does not authorize the release of information other than that specifically described below. The information requested on this form is solicited under Title 38, U.S.C. The form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164, 5 U.S.C. 552a, and 38 U.S.C and 7332 that you specify. Your disclosure of the information requested on this form is voluntary. However, if the information including Social Security Number (SSN) (the SSN will be used to locate records for release) is not furnished completely and accurately, Department of Veterans Affairs will be unable to comply with the request. The Veterans Health Administration may not condition treatment, payment, enrollment or eligibility on signing the authorization. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records notices identified as 24VA10P2 Patient Medical Record - VA and in accordance with the Notice of Privacy Practices. You do not have to provide the information to VA, but if you don't, VA will be unable to process your request and serve your medical needs. Failure to furnish the information will not have any affect on any other benefits to which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may also use this information to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes authorized or required by law. The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 2 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. ENTER BELOW THE PATIENT'S NAME AND SOCIAL SECURITY NUMBER IF THE PATIENT DATA CARD IMPRINT IS T USED. SOCIAL SECURITY NUMBER NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED VETERAN'S REQUEST: I request and authorize Department of Veterans Affairs to release the information specified below to the organization, or individual named on this request. I understand that the information to be released includes information regarding the following condition(s): DRUG ABUSE ALCOHOLISM OR ALCOHOL ABUSE TESTING FOR OR INFECTION WITH HUMAN IMMUDEFICIENCY VIRUS (HIV) SlCKLE CELL ANEMIA INFORMATION REQUESTED (Check applicable box(es) and state the extent or nature of the information to be disclosed, giving the dates or approximate dates covered by each) COPY OF HOSPITAL SUMMARY COPY OF OUTPATIENT TREATMENT TE(S) OTHER (Specify) PURPOSE(S) OR NEED FOR WHICH THE INFORMATION IS TO BE USED BY INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED TE: ADDITIONAL ITEMS OF INFORMATION DESIRED MAY BE LISTED ON THE BACK OF THIS FORM AUTHORIZATION: I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete to the best of my knowledge. I understand that I will receive a copy of this form after I sign it. I may revoke this authorization, in writing, at any time except to the extent that action has already been taken to comply with it. Written revocation is effective upon receipt by the Release of Information Unit at the facility housing the records. Redisclosure of my medical records by those receiving the above authorized information may be accomplished without my further written authorization and may no longer be protected. Without my express revocation, the authorization will automatically expire: (1) upon satisfaction of the need for disclosure; (2) on (date supplied by patient); (3) under the following condition(s): I understand that the VA health care practitioner's opinions and statements are not official VA decisions regarding whether I will receive other VA benefits or, if I receive VA benefits, their amount. They may, however, be considered with other evidence when these decisions are made at a VA Regional Office that specializes in benefit decisions. DATE (mm/dd/yyyy) SIGNATURE OF PATIENT OR PERSON AUTHORIZED TO SIGN FOR PATIENT (Attach authority to sign, e.g., POA) FOR VA USE ONLY IMPRINT PATIENT DATA CARD (or enter Name, Address, Social Security Number) TYPE AND EXTENT OF MATERIAL RELEASED DATE RELEASED RELEASED BY VA FORM JUL USE EXISTING STOCK OF VA FORM , DATED MAY 2005.