Claim for Disability Pension and/or Application for Increase in ...
Claim for Disability Pension and/or Application for Increase in ...
Claim for Disability Pension and/or Application for Increase in ...
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PART D cont<strong>in</strong>uedYOUR SERVICE DETAILSMerchant Mar<strong>in</strong>ers onlyName of shipRank <strong>or</strong>gradeName of owner<strong>or</strong> managerP<strong>or</strong>t ofregistrationNon-Australianp<strong>or</strong>ts visitedVoyage datesFromToFromToIf <strong>in</strong>sufficient space, please attach a separate sheet19 Did you serve under any othername?NoYesWhat was the name?PART EDetails of the NEW disabilities you are now claim<strong>in</strong>g aswar <strong>or</strong> defence causedIf you are not claim<strong>in</strong>g <strong>f<strong>or</strong></strong> acceptance of new disabilities go straight to Question 25.To be filled <strong>in</strong> by the VETERAN20 List the disabilities you are now claim<strong>in</strong>g <strong>and</strong> describe thesigns <strong>and</strong> symptoms.Please provide the diagnosis of the disability, if you know whatit is. If you don’t know what the diagnosis is, please describe asfully as you can the signs <strong>and</strong> symptoms that make you noticethe disability (<strong>f<strong>or</strong></strong> example, pa<strong>in</strong> <strong>in</strong> lower back, sh<strong>or</strong>tness of breath,loss of range of movement <strong>in</strong> arm).Do not <strong>in</strong>clude any <strong>in</strong>jury <strong>or</strong> disease already accepted as war<strong>or</strong> defence caused.You are requested to ask your doct<strong>or</strong> to fill <strong>in</strong> the MedicalPractitioner column next to this section be<strong>f<strong>or</strong></strong>e lodg<strong>in</strong>g your claim.To be filled <strong>in</strong> by a MEDICAL PRACTITIONERF<strong>or</strong> each disability the veteran is claim<strong>in</strong>g, providea diagnosis <strong>in</strong>dicat<strong>in</strong>g whether the diagnosis isf<strong>in</strong>al <strong>or</strong> provisional. A f<strong>in</strong>al diagnosis is preferred.Please supply a brief summary of the basis <strong>f<strong>or</strong></strong> eachdiagnosis. Please attach any rep<strong>or</strong>ts you have thatconfirms the diagnosis/es.The Department will pay you <strong>f<strong>or</strong></strong> this service acc<strong>or</strong>d<strong>in</strong>gto The Schedule of Fees.Note: An account must be lodged be<strong>f<strong>or</strong></strong>e paymentcan be made.<strong>Disability</strong>1Medical diagnosisDiagnosisSigns <strong>and</strong>symptomsBasis <strong>f<strong>or</strong></strong> diagnosisHow do you believe your service caused, contributed to, <strong>or</strong> aggravated this disability?When did you first become aware of the signs <strong>and</strong>symptoms of the disability, <strong>or</strong> aggravation of thedisability? (approx. date if known)When did the veteran first consult you <strong>f<strong>or</strong></strong> this condition?7
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