Claim for Disability Pension and/or Application for Increase in ...

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PART HDetails of your medical treatment26 Provide details of doctors andhospitals who have providedtreatment or consultation forthe disabilities which have beenaccepted as service related orthose you are now claiming.Disability treatedDate oftreatmentName of doctor/hospital etc.Type of treatmentor consultationprovided(e.g. GP, specialist)If insufficient space, please attach a separate sheet.YOUR LOCAL MEDICAL PRACTITIONER’S DETAILS27 Provide details of your localmedical practitioner (not thespecialist) who will provideongoing treatment.Local medical practioner’s nameAddressTelephone( )POSTCODEPART IDetails of your employment history(other than your service)Please complete this section even if you are retired.28 Are you currently employed?NoDate ceased workReason for ceasing work (e.g. age, illness, redundancy)YesName of current employerHow many hours per week do you work?10
PART I continuedDETAILS OF YOUR EMPLOYMENT HISTORY (OTHER THAN YOUR SERVICE)29 Provide details of youremployment history other thanyour service for the last 10 yearsor since your last claim.From(year)To(year) Type of work Name and address of employerIf insufficient space, please attach a separate sheet.30 Have the disabilities you are nowclaiming affected youremployment or your ability toseek employment at any time?NoYesPlease give detailsIf insufficient space, please attach a separate sheet.11
Page 1 and 2: Claim for Disability Pensionand/orA
Page 3 and 4: Proving your identity to DVAWhen yo
Page 6 and 7: PART B continuedVETERAN’S DETAILS
Page 8 and 9: PART E continuedDETAILS OF NEW DISA
Page 12 and 13: PART JOther paymentsIf you lodge a
Page 14 and 15: PART MDeclarationsComplete (a) OR (

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