10-0383
Catastrophically Disabled Veteran Evaluation and Approval
VA Form 10-0383 is the U.S. Department of Veterans Affairs Catastrophically Disabled Veteran Evaluation and Approval, listed under VHA on VA's page. Page 1 is the evaluation: it prints VHA's definition of a catastrophically disabled Veteran and lists the conditions under 1A, 1B and 2 that meet it, with a Completed by signature and date.
Page 2 is the Catastrophically Disabled Veteran Enrollment Approval Request. It records whether the request was Veteran initiated or VA facility initiated, the Veteran's details and representative, the conditions claimed, the record review and any clinical examination, a recommendation, approval or disapproval by the COS with a rationale, and how the Veteran and representative were notified. The form says it will be placed in the patient's record.
A Veteran can start the request, but the review, recommendation, approval and notification fields are filled in on the VA side. You can fill out the PDF free in your browser on this page and download the result without an account.
The form says VHA has defined a catastrophically disabled Veteran as one with a permanent severely disabling injury, disorder or disease that compromises the ability to carry out the activities of daily living to the degree it describes, met by the conditions under 1A, 1B or 2.
Quadriplegia and quadriparesis, paraplegia, legal blindness as the form defines it, and persistent vegetative state, each with a checkbox.
Sixteen amputation, detachment or disarticulation procedures. The form says the permanent condition results from two of them, provided the two were not on the same limb.
A note on DSM-5 and the GAF, then three measures: the Katz scale, Section GG of the IRF PAI or RAI MDS, and the global assessment of functioning, with the completed assessment tool attached.
Request or review type, date initiated, patient name, date of birth, address, residential and business phone, representative, conditions claimed, record review date, clinical examination and the recommendation.
Whether the completed assessment tool is attached, rationale for not recommending, approval by COS with a rationale for disapproval, and the notification method, first notification date and initials.
Page 2 records the request type, Veteran initiated or VA facility initiated, the date initiated and the conditions claimed by the Veteran.
Conditions the Veteran qualifies for by record review, and by clinical examination where one is needed, are listed. For each, the form says to fill out page 1.
The recommending official marks yes or no, signs and dates, notes whether the completed assessment tool is attached and gives a rationale when not recommending.
The COS marks Approved or Disapproved, signs and dates, and gives a rationale for a disapproval.
The Veteran and representative are notified by phone or by mail, with the first notification date and initials. The form says it will be placed in the patient's record.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The form says VA Form 10-0383 will be placed in the patient's record. It prints no mailing address.
The form says the goal is for the total time between the Veteran's request for evaluation and the notification of results not to exceed 35 calendar days.
NOV 2024 on both pages, matching the November 2024 revision date on VA's form page.
The form names these roles.
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The form has a Completed by signature on page 1, and a Recommended by signature and an Approval by COS signature on page 2. Page 2 records whether the request was Veteran initiated or VA facility initiated.
Page 2 lists two request or review types, Veteran initiated and VA facility initiated, and has a space for the catastrophically disabled conditions claimed by the Veteran.
It says VHA has defined a catastrophically disabled Veteran as one with a permanent severely disabling injury, disorder or disease that compromises the ability to carry out the activities of daily living to the degree it describes, met by the conditions under 1A, 1B or 2.
Section 2 says to attach the completed assessment tool, and page 2 asks whether the completed assessment tool is attached.
Page 2 records that the Veteran and the Veteran representative were notified by phone or by mail, with the first notification date and initials.
The form says the goal is for the total time between the Veteran's request for evaluation and the notification of results not to exceed 35 calendar days.
