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I Wonder If Congress Knows About This Va Directive On Veterans Medical Records?

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  • HadIt.com Elder

I Wonder if Congress Knows About This VA Directive on Veterans Medical Records?

“VHA Directive 2007-024, dated September 11, 2007 restricts the VA physician to providing a descriptive statement in the medical record regarding the current status of the veteran’s existing medical condition, disease or injury, including prognosis and degree of function.”



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I am not sure what that directive has to do with--i.e., C&P exams or in general. If it is in general, it seems designed to curtail VA doctors from lurching into anything that might actually help a veteran service-connect a problem. Just talk about the problem without getting into the cause.

One thing I am sure veterans are well aware of, if they don't have good documentation showing a nexus to military service, a diagnosis is meaningless as far as the VA is concerned.

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  • HadIt.com Elder


Welcome to Hadit. Good post

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Despite what the VA Claims says about what a VA Dr can or cannot opinion on concerning the Veterans health issues, they are directly interfereing with Dr.-Patient relationships. Beside a Religous advisor or an Attorney, one personal Dr. or a Specialist he may refer you to, have no closer relationship except maybe a love partner. If they are limited to treating only current issues without knowing their patients full medical history, how can they be sure they are giving you the correct diagnosis, treatment, and or medication?

I contend that the two Systems, Claims, and Health Service, should be seperate from the influence of the other. It's like a lawyer telling your Dr. what he can or can not opinion on concerning a Veteran's health issues in a court of law even though he had as complete a medical record of the Veterans medical history as the Attorney did, except that the Dr. had been treating the Veteran for some time and the Attorney's specialist only saw the Veteran once and only then for about an hour or so.

This Directive is biased towards the VA when it should be biased towards the Veteran.

Rockhound Rider :D

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Great Posts..Can we post this at the next Senate Veteran Affairs Hearing!! :D William

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  • HadIt.com Elder

I couldn't get the link to open, so heres the directive again.


Department of Veterans Affairs


Veterans Health Administration

Washington, DC 20420

September 11, 2007


1. PURPOSE: This Veterans Health Administration (VHA) Directive establishes policy requiring VHA health care providers, when requested, to assist veteran patients in completing non-Department of Veterans Affairs (VA) medical forms (with the exception of the completion of examination forms if a third party customarily pays health care practitioners for the examination, but does not pay VA) and by providing the veteran patients with medical statements with respect to their medical condition(s) and functionality. This Directive identifies a process to assist VHA providers in honoring requests by veterans to complete those forms (see Att. A).

2. BACKGROUND: VHA strives to be the provider of choice for all of its enrolled veterans. Completion of medical forms by health care professionals based on an examination or knowledge of the veteran’s conditions, is required under Title 38 Code of Federal Regulations (CFR) 17.38(a)(1)(xiv) as part of the medical benefits package, with the exception of the completion of examination forms if a third party customarily pays health care practitioners for the examination, but does not pay VA. NOTE: An example of such an exclusion is a Social Security Administration (SSA) examination form when the SSA may pay a private practitioner, but is prohibited from paying other Federal agencies such as VA. This regulation requires VHA providers to honor requests by veterans for assistance in completing non-VA forms regarding their current health conditions and functional impairment.

3. POLICY: It is VHA policy that clinicians must honor all requests by patients for completion of non-VHA medical forms with the exception of the completion of examination forms if a third party customarily pays health care practitioners for the examination, but does not pay VA; in addition they must honor all requests for the provision of medical statements, following procedures established by the local facility Release of Information (ROI) Office.

4. ACTION: Medical Facility Directors are responsible, no later than September 30, 2007, for establishing and implementing written facility policy addressing:

a. Non-VA Medical Forms. Veterans may ask VA health care professionals, including primary care and specialty practitioners, to complete forms that require a medical professional’s assistance. The Practitioner completes these forms at the time of the visit, or requests the veteran return to pick up these forms at another time, especially if not all information is available to the practitioner, or the form is lengthy and may cause an undue delay in the provider’s schedule. All medical forms completed on behalf of the veteran require that the individual sign VA Form 10-5345a, Individuals Request for a Copy of Their Own Health Information; local procedures must be followed for obtaining this authorization. Examples of these non-VA forms include, but are not limited to:



September 11, 2007


(1) Family Medical Leave Act forms.

(2) Life insurance application forms.

(3) Non-VA disability retirement forms.

(4) State workman’s compensation forms.

(5) State driver’s license or handicap parking forms.

b. Non-VA Medical Statements. Veterans may request a descriptive statement be put into their electronic health record regarding the current status of an existing medical condition, disease, or injury, which includes a statement of diagnosis, prognosis, and assessment of function for purposes other than VA disability claims. The veteran must sign VA Form 10-5345a, and then be responsible for forwarding their own information to the requesting facility. If the veteran requests that the form be sent directly to the requester (e.g., insurance company, etc.) then the veteran must sign VA Form 10-5345, Request for an Authorization to Release Medical Records of Health Information. NOTE: The local ROI Office is available for additional guidance.

c. Release of Information Procedures. In all cases, prior to releasing any statements or forms, the veteran is required to sign either VA Form 10-5345a or VA Form 10-5345 (see Att. A for a suggested algorithm that may be used by facilities in establishing local procedures).

d. Medical Statements to Support VA Benefits Claims. When honoring requests for medical statements by veterans for VA claims adjudication, care must be taken to avoid conflict of interest or ambiguity.

(1) Determination of causality and degrees of service connection for VA benefits is exclusively a function of the Veterans Benefits Administration (VBA). VHA providers often do not have access to military medical records, and may not be familiar with all the health issues specific to military service, such as environmental exposure. As a result, they may not feel comfortable in stating causality of a current condition. However, this does not preclude VHA providers from recording any observations on the current medical status of the veteran found in the medical record, including their current functional status. All pertinent medical records must be available for review by VBA. NOTE: VHA continues to provide compensation and pension (C&P) examinations and reports as requested by VBA, as part of any new disability claims or review process.

(2) Requests by a veteran for assistance in completing a VA disability claim are to be referred to VBA through official channels, but the clinician, if requested by the veteran, must place a descriptive statement in the veteran’s medical record regarding the current status of the veteran’s existing medical condition, disease, or injury, including prognosis and degree of function. This may then be requested by VBA for the purposes of making a claim determination.


September 11, 2007



a. VHA Handbook, 1605.1.

b. Title 38, CFR 17.38 (a) (1) (xiv) “Medical Benefits.”

6. FOLLOW-UP RESPONSIBILITY: The Office of Patient care Services (11) is responsible for the contents of this Directive. Questions may be addressed to 202-461-7114.

7. RECISSIONS: VHA Directive 2000-029, is rescinded. This VHA Directive expires

September 30, 2012.

Michael J. Kussman, MD, MS, MACP

Under Secretary for Health



E-mailed 9/11/07


VISN, MA, DO, OC, OCRO, and 200 – E-mailed 9/11/07


September 11, 2007




LOCAL PROCEDURES Process Flow Chart for Non-VA Forms.pdf


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I am thoroughly convinced, based upon things that have said to me by VA employees, that teams of lawyers instruct the VA medical side how to chart things in such a way that curtails the ability of veterans to substantiate a claim, even if the health of the veteran be damned.

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