Family members of Veterans who lived at Camp Lejeune for at least 30 days between August 1, 1953 and December 31, 1987 can be reimbursed for care of 15 covered conditions. On this two-page report the treating physician documents the diagnosis, ICD codes, diagnosis date, condition status and any active cancer treatment so VA can decide clinical eligibility for the Family Member Program.
The family member's treating physician completes and signs the whole report, adding NPI, tax ID and specialty, and affirms having reviewed the patient's signed release of information. The patient completes the program application (VA Form 10-10068) separately.
Download the current version from the source each time; forms change without notice.
Camp Lejeune Family Member Program Treating Physician Report
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The form lists 15: bladder, breast, esophageal, kidney and lung cancer, leukemia, multiple myeloma, myelodysplastic syndrome, non-Hodgkin's lymphoma, scleroderma, hepatic steatosis, renal toxicity, neurobehavioral effects, female infertility and miscarriage. The physician checks the condition that applies and gives ICD-9 or ICD-10 codes and the diagnosis date.
Yes. If the patient has more than one covered illness, a separate form must be completed for each one. Each form records its own diagnosis date, most recent visit for that condition, status (active, remission or other) and current treatment.
The form defines active as receiving chemotherapy, radiation or surgery, or having elected hospice. For each treatment the physician gives the start date and the anticipated end date, or the hospice start date, along with any ongoing or future treatment.