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Google is neither affiliated with the authors of this page nor responsible for its content.These search terms have been highlighted: inpatient records Veterans Benefits Administration M21-1, Part III

Department of Veterans Affairs Change 127

Washington, DC 20420 September 29, 2004

Veterans Benefits Manual M21-1, Part III, “Authorization and Clerical Procedures,” is changed as follows:

Pages 4-II-1 through 4-II-4: Remove these pages and substitute pages 4-II-1 through 4-II-4attached.

Paragraph 4.03b is revised to state that the servicemembers’ mental health records are not included in their Service Medical Records.

Paragraph 4.03b(1) and (2) are added to state what is contained in mental health records, where the records are retained and for how long.

          • By Direction of the Under Secretary for Benefits




                    • Renée L. Szybala, Director

Compensation and Pension Service

Distribution: RPC: 2068

FD: EX: ASO and AR (included in RPC 2068)

September 29, 2004 M21-1, Part III

Change 127

SUBCHAPTER II. RECORDS MANAGEMENT CENTER (RMC) AND

ASSOCIATED RO PROCESSING

4.03 VA OBTAINS SERVICE MEDICAL RECORDS FROM THE MILITARY

a. Service Department Transition Point Processing. Service separation points will ensure that service medical records (SMRs) are segregated from other military records and are available during the servicemembers' separation outprocessing. Transition points will provide VA with all available SMRs. The Army or Navy will advise the servicemember that his or her SMRs will be mailed directly to VA within five working days of his or her separation (this does not apply to those servicemembers who are participating in the Benefits Delivery at Discharge program since their records are made available immediately). The Marine Corps will attempt to send the SMRs to the RMC within one day. To ensure verified service data are also available, the transition points will place a legible photocopy of the servicemember's DD Form 214 into the SMR. This is a separate copy from the copy 3 which is sent to VA in Austin, Texas. The Marine Corps will photocopy "Service-2" of the DD Form 214 and attach it; when one is not available, a memo will be attached to the SMRs which identifies the length of reserve obligation and a statement that the SMRs should be forwarded to the MCRSC by the RMC. See paragraph 4.02a(4).

Note: Occasionally, SMRs are received in the RMC before the cutover dates for the four service departments. When this happens, the records are stored at the RMC.

b. Service Medical Records. The SMRs are the military health records for each veteran and typically include all physical examinations (including entrance and discharge physical examinations, as needed), medical history, all dental exams/records, panograph, clinical record cover sheets and summaries, entries from outpatient medical and dental treatments, physical profiles, medical board proceedings, and prescriptions for eyeglasses and orthopedic footwear. Physical profiles and medical board proceedings are also classified as personnel records and may appear in the personnel file as well. The SMRs do not include inpatient treatment records (clinicals), mental health records, finance records or the MPRJ (personnel) file.

(1) Mental health
records
contain information related to psychological evaluations and other

consultations relating to mental health services, including social work case records.

(2) Mental health
records
are retained by the facility that created the record.
Records
are only

retained at the facility for 5 years after the end of the calendar year the case is closed. After 5 years, the records are destroyed.

c. No Application for VA Benefits. Service Branches send SMRs to the RMC for separating servicemembers who have not applied for VA benefits. Currently, NOAA and PHS do not.

d. Application for VA Benefits. SMRs and the applications of servicemembers who apply for VA benefits at separation will generally be sent directly to the ROs of jurisdiction by the service departments. Army transition points and some for other services may send the applications and SMRs to the closest RO. Mail such applications and the SMRs to the RO of jurisdiction after certifying the DD214 or other separation documents are being received directly from the service departments. ROs servicing the transition points should use the Military Services Coordinators who have already established liaisons with the service departments to resolve any problems with SMR shipments for veterans who applied for VA benefits while on active duty awaiting discharge.

e. Transmittal Record. Transition and separation points will prepare a transmittal record DD 200 with each SMR shipment to VA. It will list names and Social Security numbers of servicemembers whose SMRs are being forwarded. This information will serve as a control document to identify and validate the SMRs shipped to both the RMC and the RO servicing the transition point. Following review and validation of the SMR shipment received, the transmittal record should be signed, a copy

4-II-1

M21-1, Part III September 29, 2004

Change 127

returned to the separation point acknowledging receipt and a copy retained at the receiving RO.

The receiving RO should input "O" into the SMR field on the LOC Screen (see paragraph 4.06).

4.04 RMC WORKFLOW

a. SMR Shipment Validation. The RMC will confirm the contents of shipments, record the date of receipt of each SMR and provide acknowledgment of receipt of each shipment to the transition point. If listed SMRs are missing from the shipment or if SMRs not listed are received, an attempt will be made to contact the transition or separation point about the problem.

b. SMRs Established in VA System. The Service Medical Records Tracking System (SMRTS) is the RMC's computer support for recording service medical record receipts. It provides a uniform method for managing and tracking the movement of SMRs into and out of the RMC. SMRTS interfaces with BIRLS. A SMRTS record is created for each SMR received.

c. All Military Records Jackets Filed. Service department health records are received from transition points in separate or multiple jackets for the same veteran. All jackets together represent the complete SMR for that veteran. Each jacket uses the same veteran identification (name and Social Security number). The contents of all jackets associated with a veteran are transferred upon a single regional office request.

d. Automatic Update to BIRLS. An SMR folder is automatically established in BIRLS. SMRTS processing generates automatic updates to BIRLS. The RMC does not enter service data into BIRLS upon receipt of service medical records. That information comes from the VADS (Veterans Assistance Discharge System) and Defense Finance and Accounting System (DFAS) interfaces.

e. SMRs Transferred to Regional Offices If Claims Folder Exists or Is Established. When the SMR folder is established in BIRLS, BIRLS determines if a claims folder already exists. If a claims folder exists, BIRLS will set the SMR folder in transit and RMC will send the record to the location of the claims folder. If an RO establishes a claims folder for a veteran whose SMRs are located at the RMC, an automatic transfer request will be generated for the RMC to transfer the SMR folder to the regional office with the claims folder. This automatic feature is only used with claims folders. SMRs are copied and sent to the lightweight (NOD) folder only upon specific regional office request. The “in transit” date is generated when the transfer request is generated and does not indicate the date the folder is physically transferred.

f. No BIRLS Record Exists At Time of Automatic Update. If no BIRLS record is found during the automatic update to BIRLS of SMRs information, a BIRLS record is created based on the veteran's name and Social Security number. The BIRLS record created may not contain complete service data, but the SMR folder will be established and reflected on the LOC screen.

Note: The RMC will process SMRs received even if a copy of the veteran's DD 214 was not received.

g. BIRLS Record Exists–No Claims Folder. If a BIRLS record exists for the servicemember whose SMR is received at the RMC, but there is no claims folder, the BIRLS record will be updated to establish the SMR folder location in BIRLS.

h. RMC Processes SMRs Received

(1) SMRs are sorted for interfiling in the RMC file bank or for transfer to regional offices for consolidation in claims or NOD folders. All SMRs to be transferred will be sorted by the regional office to which they must be mailed and associated with a folder transfer document. Upon receipt, regional offices will place SMRs in protective envelopes (VA Form 21-4582, “Service Department Records Envelope”).

4-II-2

September 29, 2004 M21-1, Part III

Change 127

(2) The RMC will only maintain SMRs for those veterans who do not have a claims folder located at a regional office or whose claims folders are located at the RMC, RPC or a FRC. The RMC will respond to all requests for copies of documents from SMRs housed there and will return SMRs to the military should there be a further need.

4.05 BIRLS INFORMATION SHOWING SMR FOLDER ESTABLISHMENT

a.
BIRLS LOC Screen.
When the SMR folder is established in BIRLS, the Folder Location

Data on the BIRLS LOC screen is updated. An indicator field labeled SMR will be set to "Y" (SMR at the RMC). Other acceptable field entries are "C" (SMR consolidated in the claim or NOD folder), "R" (SMR retired), "O" if the SMR was received at the RO not from the RMC, or blank if there is no SMR. Since no SMRs are being retired, the "R" is not used at this time. (See Figure 4.01.)

Note: Prior to October 1, 1995, the service medical records were maintained by the former Service Medical Records Center (SMRC 375). Some BIRLS LOC screens continue to show the SMRC 375 location for the SMR folder. The RMC (376) now houses the records showing 375 as well as 376.

LOC FOLDER MANAGEMENT SEQ NO 2450922490000020 10-01-1999

FILE NUMBER 222-22-4444 PN 00 NAME VET, JOE

FOLDER LOCATION DATA

FLDR CURRENT DES DATE OF PRIOR IN TRANSIT TO

TYPE LOCATION TRANSFER LOCATION STA DATE

CLAIM SYS NFE RESN

SMR 376 RMC 09-08-99

CH31 CH32/903 CH34 901 C&P JOBS SMR Y

BK BT

FOLDER DATA: REBUILT NO CLAIM FOLDER EST RSN

ESTABLISH A FOLDER FARC ACCESSION NO

TRANSFER THE FOLDER TO ROUTING SYMBOL TT23

THE FOLDER IS LOCATED AT THIS STATION

THE FOLDER IS UNAVAILABLE FOR TRANSFER:

CHARGED OUT TO FORWARD THE CLAIM TO

NEXT SCREEN

Figure 4.01. SMR Folder Established--Claims Folder Does Not Exist

b. SMRs Received At RMC–BIRLS Record Exists–Claims Folder Exists. When a claims folder already exists in BIRLS for the veteran whose SMRs are received at the RMC, the SMR folder is established and transferred in BIRLS. The IN TRANSIT TO segment for the SMR folder is automatically set to the CURRENT LOCATION of the claims folder. (See Figure 4.02.) The SMR folder DATE fields are set to current processing date. A folder transfer request is generated for the RMC to transfer the SMR. The RMC will send the SMR to the CURRENT LOCATION without updating BIRLS. This processing is like that used when a folder transfer is initiated by a regional office, but the initiation of the SMR folder transfer is system generated. If the CURRENT LOCATION of the claims folder equals RMC (Records Management Center), RPC (Records Processing Center) or FRC (Federal Records Center), the SMR folder will not be transferred. See paragraph 4.10 for processing when BIRLS shows the claims folder is at the RMC or a FRC.

4-II-3

M21-1, Part III September 29, 2004

Change 127

CHAPTER 4. REQUESTS FOR SERVICE RECORDS

LOC FOLDER MANAGEMENT SEQ NO 2450922490000020 12-01-1999

FILE NUMBER 222-22-4444 PN 00 NAME VET, JOE

FOLDER LOCATION DATA

FLDR CURRENT DES DATE OF PRIOR IN TRANSIT TO

TYPE LOCATION TRANSFER LOCATION STA DATE

CLAIM 328 CHICAGO 09-01-99

SMR 376 ST L RPC 11-13-99 328 11-13-99

CH31 CH32/903 CH34 901 C&P JOBS SMR Y

BK BT

FOLDER DATA: REBUILT NO CLAIM FOLDER EST RSN

ESTABLISH A FOLDER FARC ACCESSION NO

TRANSFER THE FOLDER TO ROUTING SYMBOL TT23

THE FOLDER IS LOCATED AT THIS STATION

THE FOLDER IS UNAVAILABLE FOR TRANSFER:

CHARGED OUT TO FORWARD THE CLAIM TO

NEXT SCREEN

Figure 4.02. SMR Folder Established and Transferred Claims Folder Already Exists

4.06 BIRLS INFORMATION SHOWING SMR FOLDER RECEIVED BY THE REGIONAL OFFICE

SMR folders received by regional offices will be recorded in BIRLS by inserting "SMR" in the blank for the statement THE ___________ FOLDER IS LOCATED AT THIS STATION on the BIRLS LOC Screen. The SMRs will be physically consolidated with the claims folders. The BIRLS update will automatically change the SMR indicator from "Y" to "C" and delete the SMR folder information. (See figure 4.03.) The "C" indicates that the SMR was consolidated in the claims folder. When an RO receives SMRs from a source other than the RMC, and the SMR indicator field is blank, a Veterans Service Center employee who has CEST or CADJ authority will enter the letter "O" in the SMR indicator field.

LOC FOLDER MANAGEMENT SEQ NO 2450922490000020 12-08-1999

FILE NUMBER 222-22-4444 PN 00 NAME VET, JOE

FOLDER LOCATION DATA

FLDR CURRENT DES DATE OF PRIOR IN TRANSIT TO

TYPE LOCATION TRANSFER LOCATION STA DATE

CLAIM 328 CHICAGO 09-01-99

CH31 CH32/903 CH34 901 C&P JOBS SMR C

BK BT

FOLDER DATA: REBUILT NO CLAIM FOLDER EST RSN

ESTABLISH A FOLDER FARC ACCESSION NO

TRANSFER THE FOLDER TO ROUTING SYMBOL TT23

THE FOLDER IS LOCATED AT THIS STATION

THE FOLDER IS UNAVAILABLE FOR TRANSFER:

CHARGED OUT TO FORWARD THE CLAIM TO

NEXT SCREEN

Figure 4.03. SMR Folder Consolidated in the Claims Folder

4-II-4

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