Patient identification
The patient's name (last, first, middle), date of birth and Social Security number.
10-10068b
Camp Lejeune Family Member Program Treating Physician Report
- Agency
- VA
- Revision
- September 2025
- Fillable fields
- 53
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-10068b: Camp Lejeune Family Member Program Treating Physician Report
VA Form 10-10068b is the U.S. Department of Veterans Affairs Camp Lejeune Family Member Program Treating Physician Report. VA's form page says to use it to provide a report from your health care provider when you apply to the Camp Lejeune Family Member Program. The form itself is a record of examination that the treating physician completes and signs.
The form is two pages. Page 1 identifies the patient, lists the conditions the form names, and asks for the diagnosis, ICD-9/10 codes, the status of the condition, treatment dates and a narrative. Page 2 holds the physician's certification, signature, contact details, Tax ID Number and National Provider Identifier (NPI), followed by a note to the physician and the Privacy Act and burden statements.
The note to the physician says VA will consider the information as part of its eligibility determination for the program. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 10-10068b
Condition history
A yes or no question on any history of the listed conditions, then checkboxes for bladder, breast, esophageal, kidney and lung cancer, leukemia, multiple myeloma, myelodysplastic syndrome, non-Hodgkin's lymphoma, scleroderma, hepatic steatosis, renal toxicity, neurobehavioral effects, female infertility and miscarriage, with dates for the last two.
Diagnosis and status
The specific diagnosis, ICD-9/10 codes, date of diagnosis, date of the most recent visit for the condition, and its status: active, remission or other.
Treatment
Radiation, chemotherapy and surgery with start and anticipated end dates, a hospice start date, other treatment and ongoing or future treatment.
Narrative
Co-morbidities, risk factors or other exposures that may have also contributed to the illness. For hepatic steatosis, renal toxicity and neurobehavioral effects, the form asks for symptoms, diagnostic tests and similar details.
Physician certification
A certification that the statement is true, the physician's signature and date, printed name, street address, city, state, zip code, Tax ID Number, NPI, email, phone and specialty.
How VA Form 10-10068b is completed
- 1
Enter the patient's details
Fill in the patient's name, date of birth and Social Security number at the top of page 1.
- 2
Mark the condition
Answer the history question and check the condition that applies. The form says to indicate the dates of miscarriage and female infertility, and to use a separate form for each illness.
- 3
Record diagnosis and treatment
Enter the diagnosis, codes, dates, status of the condition and any treatment with its start and anticipated end dates.
- 4
Write the narrative and add records
The form says historical and current medical records regarding the claimed condition are required in order to determine clinical eligibility.
- 5
Physician signs and dates it
The physician signs the certification on page 2, dates it and prints their name and practice details.
Why fill Form 10-10068b on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes and getting help
Sending the report
The form does not print a mailing address or fax number. It says: For more information go to: https://www.clfamilymembers.fsc.va.gov/
With the application
VA's page ties the report to applying to the Camp Lejeune Family Member Program. VA's forms list names VA Form 10-10068 as the program's application.
Privacy
The Privacy Act notice cites 38 USC 1787. It says the Social Security number is requested because the VA record is filed and retrieved by it, and that missing information may delay or result in denial of the benefit.
Edition
The footer reads VA FORM 10-10068b, SEP 2025. It carries OMB Control No. 2900-0822, which expires 09/30/2028, with an estimated burden of 15 minutes.
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Who uses VA Form 10-10068b?
VA's page and the form describe who is involved.
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Questions about Form 10-10068b
Who fills out VA Form 10-10068b?
The treating physician. VA's page says the form provides a report from your health care provider when you apply to the Camp Lejeune Family Member Program, and the signature section is the physician's.
Which conditions does the form list?
Bladder, breast, esophageal, kidney and lung cancer, leukemia, multiple myeloma, myelodysplastic syndrome, non-Hodgkin's lymphoma, scleroderma, hepatic steatosis, renal toxicity, neurobehavioral effects, female infertility and miscarriage.
Is one form enough for more than one condition?
No. The form says that if more than one applies, a separate form must be completed for each illness.
Do medical records go with the report?
The form says historical and current medical records regarding the claimed condition are required in order to determine clinical eligibility.
Does the report guarantee acceptance into the program?
No. The note to the physician says submission of this application does not guarantee acceptance into this program, and that eligibility is determined through VA.
Where is VA Form 10-10068b sent?
The form does not print an address or fax number. It points to https://www.clfamilymembers.fsc.va.gov/ for more information.