Va 21096a 4 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient/veteran's name and social security number at the top of the form. This information is crucial for identification purposes.
3. In Section I, indicate whether the veteran has been diagnosed with a heart condition by selecting 'Yes' or 'No.' If 'Yes,' proceed to list all applicable heart conditions in Item 1B, including their ICD codes and dates of diagnosis.
4. Move to Section II and provide a brief summary of the medical history related to the veteran's heart conditions. Be sure to include any medications required for control in Item 2E.
5. Continue through each section, ensuring that you complete all relevant fields regarding myocardial infarction, congestive heart failure, arrhythmias, and any surgical procedures undertaken.
6. Finally, review your entries for accuracy before submitting. Utilize our platform’s features to save your progress and ensure all necessary information is included.

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