SGLV-8600 - SERVICEMEMBERS’ GROUP LIFE INSURANCE...

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Unformatted text preview: SERVICEMEMBERS’ GROUP LIFE INSURANCE TRAUMATIC INJURY PROTECTION PROGRAM (TSGLI) Administered by the Office of Servicemembers’ Group Life Insurance Application for TSGLI Benefits Please submit your completed claim to your branch of service below. TSGLI Branch of Service Contacts Branch Army All Components Contact Information Phone: (800) 237-1336 Website: www.tsgli.army.mil Submit Claim by Fax (866) 275-0684 Submit Claim by E-mail tsgli@conus.army.mil Submit Claim by Postal Mail Army Human Resources Command Traumatic SGLI (TSGLI) 200 Stovall Street Alexandria, VA 22332-0470 HQ, Marine Corps Attn: WWR-TSGLI 3280 Russell Road Quantico, VA 22134 Navy Personnel Command Attn: PERS-62 5720 Integrity Drive Millington, TN 38055-6200 AFPC/DPWC 550 C Street West, Suite 14 Randolph AFB, TX 78150-4716 HQ, ARPC/DPPE 6760 E Irvington Place, #4000 Denver, CO 80280-4000 NCOIC, Customer Operations Air National Guard Bureau 1411 Jefferson Davis Hwy Suite 10718 Arlington, VA 22202 COMDT (CG-1222) 2100 2nd Street SW Washington, DC 20593-0001 PHS Compensation Branch Parklawn Building 5600 Fishers Lane, Rm 4-50 Rockville, MD 20857 U.S. Dept. of Commerce, NOAA 8403 Colesville Rd, Suite 500 Silver Spring, MD 20910 Marine Corps All Components Phone: (877) 216-0825 or (703) 432-9277 Website: https://www.woundedwarriorregiment. org/WWR.aspx Phone: (800) 368-3202 / 901-874-2501 DSN 882 Website: www.npc.navy.mil/Command Support/ CasualtyAssistance/TSGLI Phone: (800) 433-0048 Website: ask.afpc.randolph.af.mil Phone: (800) 525-0102 (888) 858-2315 t-sgli@usmc.mil Navy All Components (901) 874-2265 MILL_TSGLI@navy.mil Air Force Active Duty Air Force Reserves Air National Guard (210) 565-2348 afpc.casualty@randolph.af.mil (303) 676-6255 afpc.dppedl@arpc.denver.af.mil Phone: (703) 607-5093 (703) 607-0033 ngb.a1ps@ang.af.mil Coast Guard Phone: (202) 475-5391 (202) 475-5927 compensation@comdt.uscg.mil Public Health Services Phone: (301) 594-2963 (301) 594-2973 or (800) 733-1303 compensationbranch@psc.hhs.gov NOAA Corps Phone: (301) 713-3444 (301) 713-4140 Director.cpc@noaa.gov SGLV 8600 August 2009 (Supersedes SGLV 8600 May 2009) GL.2005.261 Ed. 8/2009 * *8732601* 8 7 3 2 6 0 1 * OMB Control Number: 2900-0671 Respondent Burden: 45 minutes GENERAL INFORMATION The Servicemembers’ Group Life Insurance Traumatic Injury Protection (TSGLI) program is a rider to Service member’s Group Life Insurance (SGLI). The TSGLI rider provides for payment to service members who are severely injured (on or off duty) as the result of a traumatic event and suffer a loss that qualifies for payment under TSGLI. TSGLI is designed to help traumatically injured service members and their families with financial burdens associated with recovering from a severe injury. TSGLI payments range from $25,000 to $100,000 based on the qualifying loss suffered. WHO IS ELIGIBLE? Effective December 1, 2005, all service members who are insured under SGLI and … n experience a traumatic event n that results in a traumatic injury n which is listed as a qualifying loss are eligible to receive a TSGLI payment. Service members who were severely injured between October 7, 2001, and November 30, 2005, in the theaters of operation for Operation Enduring Freedom or Operation Iraqi Freedom may also be eligible for a TSGLI payment. Members should contact their branch of service for more information. What is a Traumatic Event? A traumatic event is the application of external force, violence, chemical, biological, or radiological weapons, accidental ingestion of a contaminated substance, or exposure to the elements that causes damage to your body. What is a Traumatic Injury? A traumatic injury is the physical damage to your body that results from a traumatic event. What is a Qualifying Loss? A qualifying loss is a traumatic injury that is listed on the TSGLI Schedule of Losses, which lists all covered losses and payment amounts. You may view the complete Schedule of Losses and other TSGLI information at www.insurance.va.gov/sgliSite/TSGLI.htm Your branch of service TSGLI office will determine whether your injury is a qualifying loss for TSGLI purposes. HOW TO FILE A TSGLI CLAIM Filing a TSGLI claim is a three-step process in which the service member [or guardian, power of attorney or military trustee] and a medical professional must complete and submit the appropriate parts of the TSGLI Claim Form as follows: Step 1 The service member [or guardian, power of attorney or military trustee]… must complete Part A (pages 3 through 6) of the form and give it to a medical professional to complete Part B. Note: If a guardian or power of attorney completes Part A, they must include copies of letters of guardianship, letters of conservatorship, power of attorney, or durable power of attorney (if appropriate). Step 2 The medical professional… must complete Part B (pages 7 through 12). Step 3 The medical professional OR the service member [or guardian, power of attorney or military trustee]… must forward Parts A & B to the member’s branch of service TSGLI office listed on the front cover of this form. SGLV 8600 August 2009 (Supersedes SGLV 8600 May 2009) GL.2005.261 Ed. 8/2009 * *8732602* 8 7 3 2 6 0 2 * Page 1 COMPLETING THE FORM Instructions on completing the TSGLI Claim Form are included in each section. When completing the form, the service member, guardian, power of attorney or military trustee must complete the service member’s Social Security number on each page of the form. If you have questions about completing the form or if the member is deceased, please contact the branch of service TSGLI office listed on the front cover of this form. CLAIM DECISION AND PAYMENT Who Makes the Decision on My Claim? Your branch of service TSGLI office will make the decision on your claim based upon the information in Parts A and B of the TSGLI Claim Form. They will then forward their decision to the Office of Servicemembers’ Group Life Insurance (OSGLI) for appropriate action. Who Will Receive the TSGLI Payment? Payment will be made directly to the member. If the member is incompetent, payment will be made under the appropriate letters of guardianship/ conservatorship or a power of attorney to the guardian, power of attorney or military trustee on the member’s behalf. If the member dies after qualifying for payment, the payment will be made to the member’s current listed SGLI beneficiary(ies). The member must survive for seven days (168 hours) from the date of the traumatic event to be eligible for TSGLI. How the TSGLI Payment Will be Made? If your branch of service TSGLI office approves your claim, OSGLI will make the TSGLI benefit payment. There are three payment methods used for TSGLI benefits: Prudential’s Alliance Account®*, Electronic Funds Transfer (EFT), or check. If you do not choose a payment option, OSGLI will make the payment through Prudential’s Alliance Account® 1. Prudential’s Alliance Account®* — An interest-bearing account will be established in the name of the member. The member can access the money immediately using the draft book (“checkbook”). There are no monthly service fees or per-check charges and additional checks can be ordered at no additional cost. If you have any questions about Alliance, please call Alliance Customer Service toll free at 877-255-4262 or the OSGLI Claim Department toll free at 800-419-1473. Note: A service member’s legal guardian, military trustee, or power of attorney (POA) may choose the Alliance Account payment option as long as they submit proof of that appointment (i.e. the appropriate documentation) with the claim. The guardian, military trustee, or POA will not have their name added to the account, but will be able to sign Alliance Account checks on behalf of the member. 2. Electronic Funds Transfer (EFT) — Your bank account will be electronically credited with the TSGLI payment amount. Depending on your bank, payments will be credited three to five days from the date the payment is authorized. 3. Check Payment — (for guardian, power of attorney or military trustee only) A check will be issued to the guardian or power of attorney or military trustee on behalf of the member. RESPONDENT BURDEN: We need this information to allow service members who are insured under Servicemembers Group Life Insurance and suffer a loss from a traumatic injury to receive monetary compensation. 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/omb/library/ OMBINV.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this survey. PRIVACY ACT NOTICE: VA will not disclose information collected on this survey to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses identified in the VA system of records , 36VA00, Veterans and Armed Forces Personnel U.S. Government Life Insurance Records-VA, and published in the Federal Register. Your obligation to respond is voluntary. Giving us your Social Security number account information is mandatory. Applicants are required to provide their Social Security number. VA will not deny an individual benefits for refusing to provide his or her Social Security number unless the disclosure is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. * Open Solutions, Inc. is the Service Provider of the Prudential Alliance Account Settlement Option, a contractual obligation of The Prudential Insurance Company of America, located at 751 Broad Street, Newark, NJ 07102-3777. Check clearing is provided by JPMorgan Chase Bank, N.A. and processing support is provided by First Data Payment Services (FDPS). Alliance Account balances are not insured by the Federal Deposit Insurance Corporation (FDIC). Open Solutions Inc., JPMorgan Chase Bank, N.A., and First Data Payment Services are not Prudential Financial companies. SGLV 8600 August 2009 (Supersedes SGLV 8600 May 2009) GL.2005.261 Ed. 8/2009 * *8732603* 8 7 3 2 6 0 3 * Page 2 PART A - Member’s Claim Information and Authorization - to be completed by the member, guardian, power of attorney or military trustee. Service member’s Social Security Number 253 79 2526 Service member’s First Name MI Service member’s Last Name 1 Service member Information The service member, Date of Birth (mm dd yyyy) guardian, power of attorney or military trustee MUST fill in member’s Social Branch of Service Security number at the PHS Marines Army top of pages 3 through Air Force NOAA Navy 13 of this form. Address of Record (number and street) Important Note: 940 CHATAEU FOREST Contact information must be completed. City Incomplete information will delay payment of H O S C H T O N your claim. E-mail Address Ri chard J Gender Male Female Active Duty National Guard Anderson Marital Status Married Divorced Rank/Grade Single Widowed 0 1 13 19 8 5 Reserves Coast Guard SGT / E - 5 Telephone Number Apt. (if any ROAD State ZIP Code 254 GA 35408 4583545 R I C HA R D . J . A ND E R S O N 2@U S . A RMY . M I L Unit (at time of injury) BRAVO BATTERY, 4-27 FA Third Party Authorization First Name (Optional) I authorize the following person to speak with OSGLI or the Branch of Service about my claim (this can be a spouse, parent, friend or another person who is helping you with your claim). MI Last Name 2 Guardian, Power of Attorney or Military Trustee Information Complete this section ONLY if a guardian, power of attorney or military trustee will receive payment on behalf of the member. First Name MI Last Name Mailing Address (number and street) Apartment (if any) Important Note: Please include copies of the letters City of guardianship, conservatorship, or Power of Attorney, etc. Telephone Number with this form. Failure to include this documentation will delay payment of the claim. State ZIP Code Fax Number 3 Traumatic Injury Information Injuries that Qualify for TSGLI Payment In order to qualify for the TSGLI benefit, you must have experienced a traumatic event that resulted in a traumatic injury that is listed as a qualifying loss on the TSGLI Schedule of Losses. Definitions: Traumatic Event — A traumatic event is the application of external force, violence, chemical, biological, or radiological weapons, accidental ingestion of a contaminated substance, or exposure to the elements that causes damage to your body. Traumatic Injury — A traumatic injury is the physical damage to your body that resulted from a traumatic event (illness or disease is not covered). Qualifying Loss — A qualifying loss is a traumatic injury that is listed on the TSGLI Schedule of Losses. You may view the complete Schedule of Losses at www.insurance.va.gov/sgliSite/TSGLI.htm. SGLV 8600 August 2009 (Supersedes SGLV 8600 May 2009) GL.2005.261 Ed. 8/2009 * *8732604* 8 7 3 2 6 0 4 * Page 3 PART A - Member’s Claim Information and Authorization (cont’d) - to be completed by the member, guardian, power of attorney or military trustee. Service member’s Social Security Number 253 79 2526 3 Traumatic Injury Information Information About Your Loss Is the loss you are claiming the result of any of the following: a. an intentionally self-inflicted injury or an attempt to inflict such injury? b. use of an illegal or controlled substance that was not administered or consumed on the advice of a medical doctor? c. the medical or surgical treatment of an illness or disease? d. a traumatic injury sustained while committing or attempting to commit a felony? e. a physical or mental illness or disease (not including illness or disease caused by a wound infection, a chemical, biological, or radiological weapon, or the accidental ingestion of a contaminated substance)? If you answered yes… to any of the questions above, you are not eligible for TSGLI payment and should not file a claim. If you are not sure… whether your loss is a result of one of the items above, please contact your Branch of Service TSGLI Office to find out if you are eligible. Tell us about your traumatic Injury In the box below, please describe your injury and give the date, time and location where it occurred. Traumatic Injury Information Yes Yes Yes Yes No No No No Yes No SGLV 8600 August 2009 (Supersedes SGLV 8600 May 2009) GL.2005.261 Ed. 8/2009 * *8732605* 8 7 3 2 6 0 5 * Page 4 PART A - Member’s Claim Information and Authorization (cont’d) - to be completed by the member, guardian, power of attorney or military trustee. Service member’s Social Security Number 253 79 2526 1 4 Payment Options Please choose one of the three payment options below: Payment Option 1 - Prudential’s Alliance Account® To have the payment made through Prudential’s Alliance Account, fill in the mailing address below (street address only, no PO boxes.) Apartment, Ward or Room (if any) Please choose one of the three payment Service member’s Mailing Address for Payment - No P.O. Boxes options by checking the appropriate box and filling in the requested information. City Payment Option 1 – Prudential’s Alliance Account An interest-bearing account will be established in the name of the member, who can access the money using the draft book (“checkbook”). A guardian, power of attorney, or military trustee may sign Alliance Account® checks on behalf of the member if proof of appointment is submitted with the claim. Payment Option 2 – Electronic Funds Transfer Payment will be made to the bank account indicated. This option can be selected by member or, if applicable, the guardian, power of attorney or miltary trustee. State ZIP Code Payment Option 2 - Electronic Funds Transfer (EFT) To have the payment made by EFT, fill in your banking information below. A sample check is provided to help you locate the bank routing and bank account numbers. Please print clearly. Bank Routing Number Bank Account Number Checking Savings Bank Phone Number Bank Name First Name MI Last Name Customer’s Name Street Address City, State, Zip The bank routing number is always 9 digits and appears between the symbols PAY TO THE ORDER OF________________________________________________ $ ________________________________________________________ Bank Name Street Address City, State, Zip 223207349 00123012201234 1234 Dollars Check Sample Check No. 1234 The bank account number varies in length and may contain dashes or spaces. The symbol indicates the end of the account number. Bank Routing Number Bank Account Number Check Number (not needed) Payment Option 3 – Check Payment Option 3 - Check (for guardian, power of attorney or military trustee ONLY) A check will be issued To have the payment made by check, fill in the guardian or power of attorney mailing address below. to the guardian, power Apartment (if any) of attorney or military Mailing Address for Payment - No P.O. Boxes trustee on behalf of the service member. City State ZIP Code 5 Free Financial Counseling VA sponsors free financial counseling for TSGLI recipients. To receive this counseling, check the box below. I would like to receive free financial counseling with my TSGLI benefit. You should get financial counseling as soon as possible after receiving your insurance money and before making any major financial decisions. For more information on this benefit, visit www.insurance.va.gov. SGLV 8600 August 2009 (Supersedes SGLV 8600 May 2009) GL.2005.261 Ed. 8/2009 * *8732606* 8 7 3 2 6 0 6 * Page 5 PART A - Member’s Claim Information and Authorization (cont’d) - to be completed by the member, guardian, power of attorney or military trustee. Service member’s Social Security Number 253 79 2526 6 Signature Member, guardian, or power of attorney must sign here. X Signature of service member, guardian, power of attorney or military trustee Date (mm dd yyyy) WARNING: Any intentional false statement in this claim or willful misrepresentation relative thereto is subject to punishment by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001) Description of Authority to act on behalf of the member (Guardian, POA, etc.) Description of Authority: If the guardian, power of attorney or military trustee completes this section, they must also indicate their authority to act on behalf of the member (e.g. guardian, conservator, etc.) Member must complete and sign the HIPAA release on page 7 SGLV 8600 August 2009 (Supersedes SGLV 8600 May 2009) GL.2005.261 Ed. 8/2009 * *8732607* 8 7 3 2 6 0 7 * Page 6 PART A - Member’s Claim Information and Authorization (cont’d) - to be completed by the member, guardian, power of attorney or military trustee. Service member’s Social Security Number 253 79 2526 1 7 Authorization for Release of Information to Branch of Service and Office of Servicemembers’ Group Life Insurance The member, guardian, power of attorney, or military trustee must complete and sign this section. Failure to complete this section will delay payment of claim Member must complete and sign the HIPAA release, below: I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, medical examiner or other health care provider that has provided treatment, payment or services pertaining to: First Name MI Last Name Ri chard Date of Birth (mm dd yyyy) J Anderson 01 13 1985 or on my behalf (“My Providers”) to disclose my entire medical record for me or my dependents and any other health information concerning me to the Branch of Service and Office of Servicemembers’ Group Life Insurance (OSGLI) and its agents, employees, and representatives. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco, but excludes psychotherapy notes. OSGLI, an administrative unit created by Prudential to administer the Servicemembers’ Group Life Insurance Program and OSGLI administers the TSGLI program on behalf of the Department of Veterans Affairs. I authorize all non-health organizations, any insurance company, employer, or other person or institutions to provide any information, data or records relating to credit, financial, earnings, travel, activities or employment history to OSGLI. Unless limits* are shown below, this form pertains to all of the records listed above. By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization and I instruct My Providers to release and disclose my entire medical record without restriction. This authorization This information is to be disclosed under this Authorization so that my Branch of Service and OSGLI may: 1) administer claims is intended to and determine or fulfill responsibility for coverage and provision of benefits, 2) administer coverage; and 3) conduct other legally comply with the permissible activities that relate to any coverage I have applied for with OSGLI. HIPAA Privacy Rule. This authorization shall remain in force for 24 months following the date of my signature below, while the coverage is in force, except to the extent that state law imposes a shorter duration. A copy of this authorization is as valid as the original. I understand that I have the right to revoke this authorization in writing, at any time, by sending a written request for revocation to OSGLI at: 80 Livingston Avenue, Roseland, NJ 07068. I understand that a revocation is not effective to the extent that any of My Providers has relied on this Authorization or to the extent that OSGLI has a legal right to contest a claim under an insurance policy or to contest the policy itself. I understand that any information that is disclosed pursuant to this authorization may be redisclosed and no longer covered by federal rules governing privacy and confidentiality of health information. I understand that if I refuse to sign this authorization to release my complete medical record, OSGLI may not be able to process my claim for benefits and may not be able to make any benefit payments. I understand that I have the right to request and receive a copy of this authorization. *Limits, if any: NOTE: This release authorizes the branch of service and OSGLI to look at medical records. You may also be asked to provide these documents. Signature The member, guardian, power of attorney or military trustee must sign here. X Signature of service member, guardian, power of attorney or military trustee Date (mm dd yyyy) Description of Authority to act on behalf of the member (Guardian, POA, etc.) SGLV 8600 August 2009 (Supersedes SGLV 8600 May 2009) GL.2005.261 Ed. 8/2009 * *8732608* 8 7 3 2 6 0 8 * Page 7 PART B - Medical Professional’s Statement - to be completed by a medical professional who is a licensed practitioner of the healing arts acting within the scope of his/her practice. Service member’s Social Security Number 253 1 79 2526 Patient’s First Name MI Patient’s Last Name Patient Information Ri chard Date of Injury (mm dd yyyy) J Anderson Is the patient capable of handling his/her own affairs? If patient is deceased, please provide: Date of Death (mm dd yyyy) Time of Death Yes No : Cause of Death A.M. P. M. 2 Inpatient Hospitalization Information Please complete this section for ALL patients. Reason for Inpatient Hospitalization – Please give the predominant reason the patient was hospitalized Traumatic Brain Injury Other Traumatic Injury Longest Period of Inpatient Hospitalization – Please give the beginning and ending dates for the longest period of consecutive days the patient was hospitalized as an inpatient. The count of consecutive inpatient hospitalization days begins when the injured member is transported to the hospital (if applicable), includes the day of admission, continues through subsequent transfers from one hospital to another, and includes the day of discharge. Date transported Date of admittance to first hospital Date of discharge from last hospital OR Check here if still hospitalized Name and location of hospital (if more than one hospital, list all) Definition of a hospital – A hospital that is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on Accreditation of Healthcare Organizations. This includes Combat Support Hospitals, Air Force Theater Hospitals and Navy Hospital Ships. Hospital does not include a nursing home. Neither does it include an institution, or part of one, which: (1) is used mainly as a place for convalescence, rest, nursing care or for the aged; or (2) furnishes mainly homelike or Custodial Care, or training in the routines of daily living; or (3) is for residential or domiciliary living; or (4) is mainly a school 3 Qualifying Losses Suffered by Patient Instructions: Please check the box next to each loss the patient has experienced and fill in any additional information requested. Omitted information, such as sight or hearing measurements, will delay payment of the claim. Patient’s loss MUST meet the definition of loss given. Inpatient Hospitalization Inpatient hospitalization for at least 15 consecutive days Loss of Sight Loss of sight in left eye or anatomical loss of left eye Loss of sight in right eye or anatomical loss of right eye Visual Acuity and Field Best corrected visual acuity Visual Field (degrees) Loss of Speech Loss of speech Date of onset Left Eye Right Eye Date of onset/loss Inpatient hospitalization of at least 15 consecutive days as defined above. Loss of Sight is defined as: n Visual acuity in at least one eye of 20/200 or less (worse) with corrective lenses OR, Visual acuity in at least one eye of greater (better) than 20/200 with corrective lenses and a visual field of 20 degrees or less OR, Anatomical loss of eye. Loss of sight must be expected to be permanent OR must have lasted at least 120 days n n Loss of Speech is defined as: Organic loss of speech (lost the ability to express oneself, both by voice and whisper, through normal organs for speech), even if member uses an artificial appliance, such as a voice box, to simulate speech. Loss of speech must be clinically stable and unlikely to improve. SGLV 8600 August 2009 (Supersedes SGLV 8600 May 2009) GL.2005.261 Ed. 8/2009 * *8732609* 8 7 3 2 6 0 9 * Page 8 PART B - Medical Professional’s Statement (cont’d) to be completed by a medical professional who is a licensed practitioner of the healing arts acting within the scope of his/her practice. Service member’s Social Security Number 253 3 5 79 2526 Loss of Hearing Loss of hearing in left ear Loss of hearing in right ear Hearing Acuity Average Hearing Acuity (measured without amplification device) Burns 2nd degree or worse burns to the body including face and head 2nd degree or worse burns to the face only Percentage of body affected Coma Coma Date of onset Date of recovery Percentage of face affected Note: Percentage may be measured using the Rule of Nines or any other acceptable alternative. Left Ear Right Ear Date of onset Loss of hearing is defined as: Average hearing threshold sensitivity for air conduction of at least 80 decibels. Hearing Acuity must be measured at 500 Hz, 1000 Hz and 2000 Hz to calculate the average hearing threshold. Loss of hearing must be clinically stable and unlikely to improve. Qualifying Losses Suffered by Patient (cont’d) db db Burns are defined as: 2nd degree (partial thickness) or worse burns over 20% of the body including the face and head OR 20% of the face only. % % Coma is defined as: Coma with brain injury measured at a Glasgow Coma Score of 8 or less that lasts for 15, 30, 60 or 90 consecutive days. Number of days includes the date the coma began and the date the member recovered from the coma. OR Check here if coma is ongoing Glasgow score at 30 days Glasgow score at 60 days Glasgow score at 90 days Glasgow score at 15 days Important: Facial Reconstruction: If the patient is undergoing facial reconstruction, a surgeon MUST certify this section by checking the box, printing his/her name and signing on the appropriate line. Facial Reconstruction Upper or lower jaw 50% of cartilaginous nose 50% of upper lip 50% of lower lip 30% of left periorbita 30% of right periorbita 50% of left temple 50% of right temple Certification of Surgeon Date of first surgery 50% of left zygomatic 50% of right zygomatic 50% of left mandibular 50% of right mandibular 50% of left infraorbita 50% of right infraorbita 50% of chin 50% of forehead Facial Reconstruction is defined as: Reconstructive surgery to correct traumatic avulsions of the face or jaw that cause discontinuity defects, specifically surgery to correct discontinuity loss of the following: n n n n n upper or lower jaw 50% or more of the cartilaginous nose 50% or more of the upper or lower lip 30% or more of the periorbita tissue in 50% or more of any of the following facial subunits: forehead, temple, zygomatic, mandibular, infraorbital or chin. Name of Surgeon X Signature of Surgeon Date (mm dd yyyy) SGLV 8600 August 2009 (Supersedes SGLV 8600 May 2009) GL.2005.261 Ed. 8/2009 * *8732610* 8 7 3 2 6 1 0 * Page 9 PART B - Medical Professional’s Statement (cont’d) to be completed by a medical professional who is a licensed practitioner of the healing arts acting within the scope of his/her practice. Service member’s Social Security Number 253 3 5 79 2526 Amputation is: the severance or removal of a limb or part of a limb, including both severance due to a traumatic injury, or surgical removal that is required for the treatment of a traumatic injury. Amputation of Hand Amputation of left hand Amputation of right hand Amputation of Fingers Amputation of 4 fingers/ left hand Amputation of 4 fingers/ right hand Amputation of left thumb Amputation of right thumb Amputation of Foot Amputation of left foot Amputation of right foot Amputation of Toes Amputation of 4 toes/ left foot Amputation of 4 toes/ right foot Amputation of big toe/ left foot Amputation of big toe/ right foot Date of amputation Date of amputation Amputation of Foot is defined as: n n Qualifying Losses Suffered by Patient (cont’d) Date of amputation Amputation of Hand is defined as: Amputation of hand at or above* the wrist *at or above: closer to the body Date of amputation Amputation of Fingers is defined as: n Amputation of four fingers on the same hand (not including the thumb) at or above* the metacarpophalangeal joint OR, Amputation of thumb at or above the metacarpophalangeal joint. n *at or above: closer to the body Amputation of foot at or above the ankle OR, Amputation of all toes (including the big toe) on the same foot at or above the metatarsophalangeal joint. *at or above: closer to the body Amputation of Toes is defined as: n Amputation of four toes on one foot at or above the metatarsophalangeal joint (not including the big toe) Amputation of big toe at or above the metatarsophalangeal joint. OR, n *at or above: closer to the body Important: Limb Salvage: If the patient is undergoing limb salvage, a surgeon MUST certify this section by printing his/her name and signing on the appropriate line. Limb Salvage Salvage of left arm Salvage of left leg Salvage of right arm Salvage of right leg Date of first surgery Limb Salvage is defined as: A series of operations designed to avoid amputation of an arm or a leg while at the same time maximizing the limb’s functionality. The surgeries typically involve bone and skin grafts, bone resection, reconstructive, and plastic surgeries and often occur over a period of months or years. Certification of Surgeon I certify that the patient is undergoing limb salvage surgery as defined in the column to the right. Name of Surgeon Additional Comments X Signature of Surgeon Date (mm dd yyyy) SGLV 8600 August 2009 (Supersedes SGLV 8600 May 2009) GL.2005.261 Ed. 8/2009 * *87326011* 8 7 3 2 6 0 1 1 * Page 10 PART B - Medical Professional’s Statement (cont’d) to be completed by a medical professional who is a licensed practitioner of the healing arts acting within the scope of his/her practice. Service member’s Social Security Number 253 3 5 79 2526 Paralysis Quadriplegia Paraplegia Hemiplegia Uniplegia Date of onset Paralysis is defined as: Complete paralysis due to damage to the spinal cord or associated nerves, or to the brain. A limb is defined as an arm or a leg with all its parts. Paralysis must fall into one of the four categories listed below: n n n Qualifying Losses Suffered by Patient (cont’d) Description of Injury/ Assistance Needed Please provide a description of the injury and descriptions of the assistance needed to perform each ADL. Failure to provide this information may delay payment of claim. Quadriplegia - paralysis of all four limbs Paraplegia - paralysis of both lower limbs Hemiplegia - paralysis of the upper and lower limbs on one side of the body Uniplegia- paralysis of one limb n Inability to Independently Perform Activities of Daily Living (ADL) Inability to Independently Perform ADL is defined as: Inability to independently perform at least two of six ADL (bathing, continence, dressing, eating, toileting and transferring). Inability must last for at least 15 consecutive days for traumatic brain injury and at least 30 consecutive days for any other traumatic injury. The patient is considered unable to perform an activity independently only if he or she REQUIRES assistance to perform the activity. If the patient is able to perform the activity by using accommodating equipment, such as a cane, walker, commode, etc., the patient is considered able to independently perform the activity without requiring assistance. Requires Assistance is defined as: n n n physical assistance (hands-on), stand-by assistance (within arm’s reach), verbal assistance (must be instructed because of cognitive impairment), without which the patient would be INCAPABLE of performing the task. What is the What is the predominant reason the patient is/was unable to independently perform ADL? predominant reason Traumatic Brain Injury Other Traumatic Injury the patient is/was (Please describe injury and give reason(s) it resulted in inability to perform activities of daily living.) unable to independently perform ADL? Check the predominant reason the patient cannot independently perform ADL and Patient is UNABLE to bathe independently if… Unable to bathe independently describe the injury in the box provided. Start date End date He/she requires assistance from another person to bathe (including sponge bath) more than one part of the body or get Which ADL is the in or out of the tub or shower. patient unable to Describe assistance needed: OR Check here if inability is ongoing perform? Check each ADL Type of assistance required (check all that apply) the patient cannot physical assistance (hands-on) verbal assistance (must be perform; instructed because of AND; stand-by assistance cognitive impairment) Fill in the dates (within arm’s reach) inability began and ended or indicate Patient is UNABLE to maintain continence Unable to maintain continence independently inability is ongoing. independently if… Start date End date He/she is partially or totally unable to control bowel and bladder function or requires assistance from another person to manage catheter or colostomy bag. Describe assistance needed: verbal assistance (must be instructed because of cognitive impairment) OR Check here if inability is ongoing Type of assistance required (check all that apply) physical assistance (hands-on) stand-by assistance (within arm’s reach) SGLV 8600 August 2009 (Supersedes SGLV 8600 May 2009) GL.2005.261 Ed. 8/2009 * *87326012* 8 7 3 2 6 0 1 2 * Page 11 PART B - Medical Professional’s Statement (cont’d) to be completed by a medical professional who is a licensed practitioner of the healing arts acting within the scope of his/her practice. Service member’s Social Security Number 253 3 5 79 2526 Inability to Independently Perform Activities of Daily Living (ADL) (cont’d) Unable to dress independently Start date Patient is UNABLE to dress independently if… End date He/she requires assistance from another person to get and put on clothing, socks or shoes. Describe assistance needed: Qualifying Losses Suffered by Patient (cont’d) Require Assistance is defined as: n physical assistance (hands-on), n stand-by assistance (within arm’s reach), n verbal assistance (must be instructed because of cognitive impairment), without which the patient would be INCAPABLE of performing the task. OR Check here if inability is ongoing physical assistance (hands-on) stand-by assistance (within arm’s reach) verbal assistance (must be instructed because of cognitive impairment) Patient is UNABLE to eat independently if… End date He/she requires assistance from another person to: n Type of assistance required (check all that apply) Unable to eat independently Start date get food from plate to mouth OR, take liquid nourishment from a straw or cup OR, OR Check here if inability is ongoing n he/she is fed intravenously or by a feeding tube Describe assistance needed: Type of assistance required (check all that apply) physical assistance (hands-on) stand-by assistance (within arm’s reach) verbal assistance (must be instructed because of cognitive impairment) Unable to toilet independently Start date Patient is UNABLE to toilet independently if… End date He/she must use a bedpan or urinal to toilet OR, he/she requires assistance from another person with any of the following: going to and from the toilet, getting on and off the toilet, cleaning self after toileting, getting clothing off and on. Describe assistance needed: OR Check here if inability is ongoing Type of assistance required (check all that apply) physical assistance (hands-on) stand-by assistance (within arm’s reach) verbal assistance (must be instructed because of cognitive impairment) Unable to transfer independently Start date End date Patient is UNABLE to transfer independently if… He/she requires assistance from another person to move into or out of a bed or chair. Describe assistance needed: OR Check here if inability is ongoing Type of assistance required (check all that apply) physical assistance (hands-on) stand-by assistance (within arm’s reach) verbal assistance (must be instructed because of cognitive impairment) SGLV 8600 August 2009 (Supersedes SGLV 8600 May 2009) GL.2005.261 Ed. 8/2009 * *87326013* 8 7 3 2 6 0 1 3 * Page 12 PART B - Medical Professional’s Statement (cont’d) to be completed by a medical professional who is a licensed practitioner of the healing arts acting within the scope of his/her practice. Service member’s Social Security Number 253 4 5 79 2526 To your knowledge, were any of the losses indicated in Part B due to: a. an intentionally self-inflicted injury or an attempt to inflict such injury, b. use of an illegal or controlled substance that was not administered or consumed on the advice of a medical doctor, c. the medical or surgical treatment of an illness or disease, d. a physical or mental illness or disease (not including illness or disease caused by a pyogenic infection, a chemical, biological, or radiological weapon, or the accidental ingestion of a contaminated If yes, please explain below: Other Information 5 Medical Professional’s Comments Use this block to provide any additional information about the patient’s injuries. When a narrative description is required, please be complete and concise. 6 5 Medical Professional’s Information Name of Medical Professional First Name MI Last Name Medical Professional’s Address (number and street) Suite City State ZIP Code Telephone Number Fax Number E-mail Address Specialty Medical Degree 7 Medical Professional’s Signature I have observed the patient’s loss. I have not observed the patient’s loss, but I have reviewed the patient’s medical records. This Medical Professional’s Statement is based upon my examination of the patient, and/or, a review of pertinent medical evidence. I understand the patient and/or I may be asked to provide supporting documentation to validate eligibility under the law. Date (mm dd yyyy) Signature X WARNING: Any intentional false statement in this claim or willful misrepresentation relative thereto is subject to punishment by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001) SGLV 8600 August 2009 (Supersedes SGLV 8600 May 2009) GL.2005.261 Ed. 8/2009 * *87326014* 8 7 3 2 6 0 1 4 * 110094-0609 Page 13 ...
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