VA Form 29-8158 Attending Physician's Statement

OMB Approved No. 2900-0324
Respondent Burden: 45 Minutes

ATTENDING PHYSICIAN’S STATEMENT
Important Notice About Information Collection We need this information to determine, establish or verify your eligibility for VA Insurance benefits (38 U.S.C. 5902) Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of 45 minutes to review the instructions, find the information, and complete this 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.whitehouse.gov/library/omb/OMBINVC.html#VA. If desired, you can call 1-800-827-1000 to get information
on where to send comments or suggestions about this form. Privacy Act Notice The 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 5, Code of Federal Regulations 1.526 for routine uses identified in the VA system of records, 36VA00, Veterans and Armed Forces Personnel U.S.
Government Life Insurance Records-VA, published in the Federal Register. Your obligation to respond is voluntary, but your failure to provide us the information could impede processing.
Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. The 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 responses you submit are considered
confidential (38 U.S.C. 5701).
1. NAME OF APPLICANT (Type or print)

2. INSURANCE FILE NO.

NOTICE TO APPLICANT
Any examination required in connection with V, RS, W, or RH insurance or in
connection with reinstatement or change of plan of "J" insurance may be made by
medical officers in active service or physicians of the U.S. Public Health Service, for
those entitled, or may be made free of charge by a physician of the VA Regional Office
or Medical Center. The examination may also be made at the applicant’s own expense
by a physician duly licensed for practice of medicine by a State, Territory or
Possession of the United States, or District of Columbia, who is not related to the
applicant, by blood or marriage, associated with his/her business, or financially
interested in the granting of this insurance. Any medical examination required in
connection with the insurance of the Total Disability Income Provision to "J"
insurance must be made at the applicant’s own expense.

NOTICE TO PHYSICIAN
Please furnish all pertinent information. If more space is needed, you may
use the reverse of this form. The completed form should be sent to:
Department of Veterans Affairs
Regional Office and Insurance Center
P.O. Box 7208
Philadelphia, PA 19101

SECTION I - TO BE COMPLETED BY APPLICANT (Complete applicable
3. DATE FIRST SEEN BY PHYSICIAN

4. TIME LOST FROM WORK

5. DATE RETURNED TO WORK

6. DATE OF ILLNESS, DISEASE OR INJURY - SYMPTOMS AND NATURE OF IMPAIRMENT

7. SIGNATURE OF APPLICANT (Do not print)

8. DATE

SECTION II - TO BE COMPLETED BY PHYSICIAN (Complete applicable items)
9. DETAILED HISTORY OF SYMPTOMS AND TREATMENT (Medical, surgical - including any complications)

10. NAMES AND ADDRESSES OF HOSPITALS WHERE TREATED - DATES OF HOSPITALIZATION

11. NAMES AND ADDRESSES OF ATTENDING PHYSICIANS - DATES OF TREATMENT

12. PHYSICAL EXAMINATION - GIVE SPECIFIC ATTENTION TO AREAS INVOLVED

13. X-RAY REPORT (Do not send film)

15. DIAGNOSIS

14. LABORATORY REPORT

16. IS CONDITION

17. PROGNOSIS

STATIONARY
PROGRESSIVE
RECURRENT
18. NAME OF PHYSICIAN (Type of print)

19. DATE EXAMINED

21. SIGNATURE OF PHYSICIAN (Do NOT print)

22. ADDRESS OF PHYSICIAN (City, county, State and ZIP Code)

VA FORM
DEC 2003

29-8158

20. STATE IN WHICH LICENSED TO PRACTICE

EXISTING STOCKS OF VA FORM 29-8158, MAR 2002, WILL
BE USED.