Page PO Box 34500 Washington DC 20043Treating Physician Information FormThis form may be completed by the Physician or ID: 893035
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1 Treating Physician InformationForm Pag
Treating Physician InformationForm Page P.O. Box 34500, Washington, D.C. 20043 Treating Physician Information FormThis form may be completed by the Physician or the Claimant ** Earliest Date of Symptom (month/year) Date of First Diagnosis (month/year) Treating Physician InformationForm Page P.O. Box 34500, Washington, D.C. 20043 Treating Physician Contact InformationThis form may be completed by the Physician or the Claimant **Please complete a separate version of this form for each treating physician.Claimant Name_____________________________________________VCF Claim Number:VCF__ __ __ __ __ __ __Physician Name:__________________________________________
2 ___Physician Address:___________________
___Physician Address:___________________________________________City__________________State____ Zip____________Physician Phone:____________________________________________Physician Fax:___________________________________________Physician Email:_____________________________________________Please also provide the state(s) where the physician islicensed to practice medicine, the corresponding license number(s) and any practice specialties along with the corresponding AMA Physician Specialty Code.State(s) and license number(s): ________________________________________________________________________________________________________________________________Specialties and AMA Physician Specialty Codes:________________________________________________________________________________________________________________________________________________________________________________________________