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andor need for care) /TU (Probable duration of condition and/or need for care) /Type /Annot /StructParent 41 >> endobj 41 0 obj << /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Ff 49152 /Kids [158 0 R 159 0 R] /T (Is the veteran undergoing medical treatment recuperation or therapy for this condition) /TU (Is the veteran undergoing medical treatment, recuperation, or therapy for this condition) >> endobj 42 0 obj << /AP << /N 160 0 R >> /DA (/Helv 0 Tf 0 g) /DR << /Encoding << /PDFDocEncoding 155 0 R >> /Font << /Helv 156 0 R >> >> /F 4 /FT /Tx /P 61 0 R /Rect [63 281.52 574.44 305.88] /Subtype /Widget /T (If yes please describe medical treatment recuperation or therapy) /TU (If yes, please describe medical treatment, recuperation or therapy) /Type /Annot /StructParent 44 >> endobj 43 0 obj << /DA (/ZaDb 0 Tf 0 g) /FT /Btn /Ff 49152 /Kids [161 0 R 162 0 R] /T (Will the veteran need care for a single continuous period of time including any time for treatment and recovery) /TU (Will the veteran need care for a single continuous period of time, including any time for treatment and recovery) >> endobj 44 0 obj << /AP << /N 163 0 R >> /DA (/Helv 0 Tf 0 g) /DR << /Encoding << /PDFDocEncoding 155 0 R >> /Font << /Helv 156 0 R >> >> /F 4 /FT /Tx /P 61 0 R /Rect [377.4 114.24 575.4 138.6] /Subtype /Widget /T (If yes estimate the beginning and ending dates for this period of time) /TU (If yes, estimate the beginning and ending dates for this period of time) /Type /Annot /StructParent 47 >> endobj 45 0 obj << /AP << /D << /Off 164 0 R /On 165 0 R >> /N << /Off 166 0 R /On 167 0 R >> >> /AS /Off /DA (/ZaDb 0 Tf 0 g) /F 4 /FT /Btn /MK << /CA (n) >> /P 61 0 R /Rect [389.28 87.6 401.76 97.44] /Subtype /Widget /T (Will the veteran require periodic followup treatment appointments Yes) /TU (Will the veteran require periodic follow-up treatment appointments? 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/Form /P 283 0 R /Pg 60 0 R /Alt <4865616C746820636172652070726F76696465729073206E616D6520616E6420627573696E6573732061646472657373> /K 550 0 R >> endobj 428 0 obj << /Type /StructElem /S /Form /P 283 0 R /Pg 60 0 R /Alt (undefined) /K 551 0 R >> endobj 429 0 obj << /Type /StructElem /S /Form /P 283 0 R /Pg 60 0 R /Alt (undefined) /K 552 0 R >> endobj 430 0 obj << /Type /StructElem /S /Form /P 283 0 R /Pg 60 0 R /Alt (Email) /K 553 0 R >> endobj 431 0 obj << /Type /StructElem /S /Form /P 283 0 R /Pg 60 0 R /K 554 0 R >> endobj 432 0 obj << /Type /StructElem /S /Form /P 283 0 R /Pg 60 0 R /K 555 0 R >> endobj 433 0 obj << /Type /StructElem /S /Form /P 283 0 R /Pg 60 0 R /Alt (Type of Practice/Medical Specialty) /K 556 0 R >> endobj 434 0 obj << /Type /StructElem /S /Form /P 283 0 R /Pg 60 0 R /Alt (a DOD health care provider) /K 557 0 R >> endobj 435 0 obj << /Type /StructElem /S /Form /P 283 0 R /Pg 60 0 R /Alt (a VA health care provider) /K 558 0 R >> endobj 436 0 obj << /Type /StructElem /S /Form /P 283 0 R /Pg 60 0 R /Alt (a DOD TRICARE network authorized private health care provider) /K 559 0 R >> endobj 437 0 obj << /Type /StructElem /S /Form /P 283 0 R /Pg 60 0 R /Alt (a DOD non-network TRICARE authorized private health care provider) /K 560 0 R >> endobj 438 0 obj << /Type /StructElem /S /Form /P 283 0 R /Pg 60 0 R /Alt (other health care provider) /K 561 0 R >> endobj 439 0 obj << /Type /StructElem /S /Form /P 318 0 R /Pg 61 0 R /Alt (A continuation of a serious injury or illness that was incurred or aggravated when the covered veteran was a) /K 562 0 R >> endobj 440 0 obj << /Type /StructElem /S /Form /P 318 0 R /Pg 61 0 R /Alt (A physical or mental condition for which the covered veteran has received a U.S. Department of Veterans) /K 563 0 R >> endobj 441 0 obj << /Type /StructElem /S /Form /P 318 0 R /Pg 61 0 R /Alt <4120706879736963616C206F72206D656E74616C20636F6E646974696F6E2074686174207375627374616E7469616C6C7920696D70616972732074686520636F7665726564207665746572616E9073206162696C69747920746F20736563757265206F7220666F6C6C6F772061> /K 564 0 R >> endobj 442 0 obj << /Type /StructElem /S /Form /P 318 0 R /Pg 61 0 R /Alt (An injury, including a psychological injury, on the basis of which the covered veteran is enrolled in the Department) /K 565 0 R >> endobj 443 0 obj << /Type /StructElem /S /Form /P 318 0 R /Pg 61 0 R /Alt (None of the above) /K 566 0 R >> endobj 444 0 obj << /Type /StructElem /S /Form /P 318 0 R /Pg 61 0 R /Alt (Is the veteran being treated for a condition which was incurred or aggravated by service in the line of duty on) /K 567 0 R >> endobj 445 0 obj << /Type /StructElem /S /Form /P 318 0 R /Pg 61 0 R /Alt (Is the veteran being treated for a condition which was incurred or aggravated by service in the line of duty on) /K 568 0 R >> endobj 446 0 obj << /Type /StructElem /S /Form /P 318 0 R /Pg 61 0 R /Alt (Approximate date condition commenced) /K 569 0 R >> endobj 447 0 obj << /Type /StructElem /S /Form /P 318 0 R /Pg 61 0 R /Alt (Probable duration of condition and/or need for care) /K 570 0 R >> endobj 448 0 obj << /Type /StructElem /S /Form /P 318 0 R /Pg 61 0 R /Alt (Is the veteran undergoing medical treatment, recuperation, or therapy for this condition) /K 571 0 R >> endobj 449 0 obj << /Type /StructElem /S /Form /P 318 0 R /Pg 61 0 R /Alt (Is the veteran undergoing medical treatment, recuperation, or therapy for this condition) /K 572 0 R >> endobj 450 0 obj << /Type /StructElem /S /Form /P 318 0 R /Pg 61 0 R /Alt (If yes, please describe medical treatment, recuperation or therapy) /K 573 0 R >> endobj 451 0 obj << /Type /StructElem /S /Form /P 318 0 R /Pg 61 0 R /Alt (Will the veteran need care for a single continuous period of time, including any time for treatment and recovery) /K 574 0 R >> endobj 452 0 obj << /Type /StructElem /S /Form /P 318 0 R /Pg 61 0 R /Alt (Will the veteran need care for a single continuous period of time, including any time for treatment and recovery) /K 575 0 R >> endobj 453 0 obj << /Type /StructElem /S /Form /P 318 0 R /Pg 61 0 R /Alt (If yes, estimate the beginning and ending dates for this period of time) /K 576 0 R >> endobj 454 0 obj << /Type /StructElem /S /Form /P 318 0 R /Pg 61 0 R /Alt (Will the veteran require periodic follow-up treatment appointments? Yes) /K 577 0 R >> endobj 455 0 obj << /Type /StructElem /S /Form /P 318 0 R /Pg 61 0 R /Alt (No) /K 578 0 R >> endobj 456 0 obj << /Type /StructElem /S /Form /P 318 0 R /Pg 61 0 R /Alt (If yes, estimate the treatment schedule) /K 579 0 R >> endobj 457 0 obj << /Type /StructElem /S /Form /P 359 0 R /Pg 62 0 R /Alt (Is there a medical necessity for the veteran to have periodic care for these follow-up treatment appointments) /K 580 0 R >> endobj 458 0 obj << /Type /StructElem /S /Form /P 359 0 R /Pg 62 0 R /Alt (Is there a medical necessity for the veteran to have periodic care for these follow-up treatment appointments) /K 581 0 R >> endobj 459 0 obj << /Type /StructElem /S /Form /P 359 0 R /Pg 62 0 R /Alt (Is there a medical necessity for the veteran to have periodic care for other than scheduled follow-up treatment) /K 582 0 R >> endobj 460 0 obj << /Type /StructElem /S /Form /P 359 0 R /Pg 62 0 R /Alt (Is there a medical necessity for the veteran to have periodic care for other than scheduled follow-up treatment) /K 583 0 R >> endobj 461 0 obj << /Type /StructElem /S /Form /P 359 0 R /Pg 62 0 R /Alt (If yes, please estimate the frequency and duration of the periodic care [1]) /K 584 0 R >> endobj 462 0 obj << /Type /StructElem /S /Form /P 359 0 R /Pg 62 0 R /Alt (If yes, please estimate the frequency and duration of the periodic care [2]) /K 585 0 R >> endobj 463 0 obj << /Type /StructElem /S /Form /P 359 0 R /Pg 62 0 R /Alt (Signature of Health Care Provider) /K 586 0 R >> endobj 464 0 obj << /Type /StructElem /S /Form /P 359 0 R /Pg 62 0 R /Alt (Date) /K 587 0 R >> endobj 465 0 obj << /Length 39 /BBox [0 0 12.48 9.84] /FormType 1 /Matrix [1 0 0 1 0 0] /Resources << /ProcSet [/PDF] >> /Subtype /Form /Type /XObject >> stream 0.5 0.5 0.5 rg 1.2 1.2 10.08 7.44 re f endstream endobj 466 0 obj << /Length 64 /BBox [0 0 12.48 9.84] /Filter /FlateDecode /FormType 1 /Matrix [1 0 0 1 0 0] /Resources << /ProcSet [/PDF] >> /Subtype /Form /Type /XObject >> stream H, @! 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