C & P Records Problem

[Kevin J]

I recently had a C&P exam done at the Orlando VAMC and when I go to the ROI office they tell me that they are not allowed to release the C&P medical records because it is still being rated. There is a sign on the wall that says per the St. Petersburg Regional Office that they can not give out the records. Is that allowed since it is a medical record, aren't we supposed to have unlimited access per federal law to our records? Can the regional office get away with this and what should I do to get my complete records? Has anyone else run into this problem and the Orlando office?

Thanks,

[sharon]

Request the exam results directly from the RO. They have to release them under the freedom of information act.

[cowgirl]

Sharon, could be the exam rules are changing, been told myself mental health exams like Ptsd aren't releasable until after the rating. Do you have the current VA regulation that will release themunder FOIA ? Maybe changes are happening. Thank you for your help.

Cowgirl

Request the exam results directly from the RO. They have to release them under the freedom of information act.

[LarryJ]

I recently had a C&P exam done at the Orlando VAMC and when I go to the ROI office they tell me that they are not allowed to release the C&P medical records because it is still being rated. There is a sign on the wall that says per the St. Petersburg Regional Office that they can not give out the records. Is that allowed since it is a medical record, aren't we supposed to have unlimited access per federal law to our records? Can the regional office get away with this and what should I do to get my complete records? Has anyone else run into this problem and the Orlando office?

Thanks,

I do believe that they are looking at your C&P exam as an "administrative record" as opposed to a "medical record". And, in actuallity, it is an administrative record. I mean by this, that the C&P exam is not meant to be a medical record whereby you receive any "medical treatment" due to the exam, there are no treatment plans generated by this exam, no medication is prescribed, etc.

If it is an administrative record, then, yes, they can retain it without your being able to access it, until which time that they see fit to release it.

Or, at least, that's the way it looks from here in Texas :P !

[tssnave]

Kevin,

Please ask the Orlando VAMC under what regulation or law are they denying you a copy of your C&P exam. Simply stating that the St Pete VARO doesn't allow it is not a governing rule or regulation or law. If you cannot get a straight answer then ask the head of the VAMC in writing.

Also, send the same letter to the VARO asking them under what law they are denying you access to a copy of your C&P exam.

Please let us know what the outcome of your query is.

If you get the run around, I would suggest you send an email to Larry Strickland at vawatchdog.org and run this past him and see if he can shake out what's going on from his sources.

If this flies and they are able to deny us a copy of our C&P exam until after they decide to rate a claim (which can take months and/or years) then we are left in the dark and have to wait until after the rating to even request a copy - and then what happens to the poor vet who doesn't get a copy of his Cfile and/or C&P exam until after the 1 year appeal period. Lots of vets complain it takes them over a year to get their Cfile. This does not bode well for the veteran and I'd like to know under what authority they are denying vets access to their medical records.

Thanks,

TS Snave

[tssnave]

Cowgirl,

Who told you "been told myself mental health exams like Ptsd aren't releasable until after the rating"?

Please ask them under what authority the VA is going to deny vets access to evidence in their files. I don't mean the VARO said so, what law or regulation or FAST letter is the VARO standing on?

I am curious if this is just the VA blowing smoke up our skirts or if there has been some legal change to deny vets access to their Cfile information.

Thanks,

TS

[tssnave]

Larry,

You bring up an interesting point about administrative records vs medical records but I don't know if it actually has any bearing on the question at hand since we, the vet, can request a copy of our administrative Cfile at any time in the process under the FOIA. Now, whether or not the VA sees fit to send it to us is another matter all together but getting a copy of your Cfile is a protected right that has no time limitations on it therefore, I do not understand why or how or under what regulation or point of law that they could deny a vet access to a copy of their Cfile (which is why I am asking anyone who is a part of this or has any knowledge of this practice to ask under what authority they are being denied access to information in their Cfile.

Part of the reason I think this may be smoke up our skirts is because when I was working my claim Pete was always telling us to get a copy of our C&P exam and Cfile. Well, I literally called 3 different times trying to get a copy of my C&P exam and everytime they said they didn't have it and I'd have to get it from the VARO. I didn't want to request my entire Cfile because I thought that would delay rating my claim and just wanted the C&P exam. Each time I'd call and be told no, I'd post on hadit and Pete would reiterate that I was allowed to have a copy of my C&P exam and I'd call the C&P exam center back.

Finally, in my last call, I got a "wrong" connection to out patient surgery and it was an old surg nurse who told me they didn't have it at the exam location because all med records were stored at the big hospital in another city. That the C&P exam site was a satellite station of the hospital and he even gave me their central number and told me to ask for medical records. I call the hospital, ask for med records and a guy immediately faxes me a request, I fax it back, and I have a copy of my C&P exam in my hands in less than 72 hours.

Point being, had I listened to the VA and not Pete, I would have probably given up after my first request and certainly after my second request but Pete was so adamant that I should be able to get a copy of my C&P exam that I kept at it until I got lucky and found out that the reason they were saying I couldn't have it was because they literally didn't have it themselves. Now why the med records folks at the exam site never bothered to tell me that and why it took a misconnection to out patient surgery for me to find out how to go about it is just ridiculous but it happened.

Long story short, just because the VA says they can't do something doesn't for one minute mean that's accurate.

I hope Kevin J and Cowgirl can get to the bottom of this in case it is a new wave of hassle the VA has in store for vets.

Thanks,

TS

Edited September 12, 2009 by tssnave (see edit history)

[blanco63]

Request the exam results directly from the RO. They have to release them under the freedom of information act.

C & P exam results are not available from the RO but they sure are easily available from the ORLANDO VAMC now not after the rating/decision. I received mine in one week from the LEBANON PA VAMC in july, 2009, and i have not rcd a decision yet. OK, since i am the sarcastic one, let me add, from where do you get all of this incorrect, i mean good, info ? I give a lot of advice but nobody listens to the new, dumb, young guy but i don't care. I know i got three increases in 1 year by using reconsiderations. i never heard of disagree, dro review, dro hearing, bva appeal. i know recon but keep listening to your vso's and appeal appeal appeal and wait 3 to 4 years for nothing,HA HA HA. No wonder most of you don't get anywhere. good luck, the dummy in pa (with the big checks) B) :P

[LarryJ]

C & P exam results are not available from the RO but they sure are easily available from the ORLANDO VAMC now not after the rating/decision. I received mine in one week from the LEBANON PA VAMC in july, 2009, and i have not rcd a decision yet. OK, since i am the sarcastic one, let me add, from where do you get all of this incorrect, i mean good, info ? I give a lot of advice but nobody listens to the new, dumb, young guy but i don't care. I know i got three increases in 1 year by using reconsiderations. i never heard of disagree, dro review, dro hearing, bva appeal. i know recon but keep listening to your vso's and appeal appeal appeal and wait 3 to 4 years for nothing,HA HA HA. No wonder most of you don't get anywhere. good luck, the dummy in pa (with the big checks) B) :P

.....and the attitude.

[timetowinarace]

I wouldn't think a C&P exam could be kept from a claimant based on it being an adminstrative document. It should be considered 'medical evidence' and I can't see how evidence can be withheld from a claiment while a decision is being made based on that evidence.

I too am very interested to find out what legal grounds the VA could use to deny veterans access to evidence used in deciding a claim. Especially when it could be considered as evidence against or contrary to the claim and treating physician.

To me, that seems to be in the same context as if they were to deny a claiment to veiw the rating criteria untill a decision is made.

It's quite impossible to provide proof of the claim if you do not know the information necissary to do so. The claims proccess should not be an algabra equation, X+Y=40%.

[JamesBreckenridge]

Yeah. Hell, I'm "the enemy" here and I know better than to act like that. :P

To address the question about release of info (specifically, PTSD C&P exam results), I don't know of any reason why the veteran would not be entitled to a copy of it at any time. That said, something is tickling my brain about "special handling" of PTSD evidence. I'll ask around, but my gut tells me that there's no reason you can't have a copy regardless of whether the claim has been rated or not. I'll try to find out.

As for the Regional Office not having a copy of it... that sounds like bunk to me. ALL of your VAMC records are stored electronically. Most notably, this includes C&P exams (usually they're in the computer within a day or two) and everyday clinical notes. The regional office may not have a yellow hardcopy of your C&P exam, but to go into the computer system and reprint it is trivially easy.

There may be some administrative policies in place for privacy and other reasons that complicate things. Like I said, I'll check around and see if there's some Official Guidance on this issue.

.....and the attitude.

[timetowinarace]

C & P exam results are not available from the RO but they sure are easily available from the ORLANDO VAMC now not after the rating/decision. I received mine in one week from the LEBANON PA VAMC in july, 2009, and i have not rcd a decision yet. OK, since i am the sarcastic one, let me add, from where do you get all of this incorrect, i mean good, info ? I give a lot of advice but nobody listens to the new, dumb, young guy but i don't care. I know i got three increases in 1 year by using reconsiderations. i never heard of disagree, dro review, dro hearing, bva appeal. i know recon but keep listening to your vso's and appeal appeal appeal and wait 3 to 4 years for nothing,HA HA HA. No wonder most of you don't get anywhere. good luck, the dummy in pa (with the big checks) B) :P

You got my curiosity going. I've been here for several years and don't think I've seen anyone find Hadit that wasn't looking for claims advice. I am assuming from your post that you know way more than anyone else and didn't come here looking for advice. But, I'm confused about that too. Three increases in a year, yet to hear you tell it I'd have thought you would have gotten it right the first time. And did I read that right, you still have an open claim? That just seems odd for a person with your insight into the VA system.

[Berta]

I brought up to the H VAC some time ago that we should have a copy of the C & P attached to the SOCs.

Better yet is to get copy of the C & P exam results as soon as it is completed.It can give you a legup as top what to expect in the decision.

Many vets don't even know they have rights to the C & P exams. It sure is news to me if they can hold back results of a PTSD C & P-and what for?

Having had C & P exams manipulated and parsed in SSOC I used to get-I feel if the VA is going to start giving us the Due Process that the CAVC has pointed out in the recent Cushman V Shenseki decision-as our right as property interest per the 5th amendent ----

then we certainly have the right to Discovery (what Civil courts have)

meaning we should be given the same evidence the VA is using for our claims decisions.

I used Cushman already as citation on evidence list for letter I sent to Regional Counsel up here in NY-

The RC lawyer already misunderstood the regs I sent as well as older BVA decision regarding an offset FTCA release-when I called him- so a letter with legal evidence is always better than trying to get anywhere by phone.

C & P exam results are the controlling factor in VA decisions. The rater must back up any award they make with medical evidence- to include the C & P exam.

As well as support any reason for denials with a C & P exam.

What gets me is that they can ignore-like in my case- 3 IMOs for years -yet they never seem to lose the C & P exam results.

I again suggest to knock down poor C & P exams line by line citing the exact evidence in your clinical record that creates strong rebuttal to the C & P.

and better yet get an IMO from real doctor-particularily if the C & P examiner is not qualified to render their opinion.

When the BVA wanted a cardio to give me an opinion-I got a VA PA instead. It was very easy to knock down his opinion.

I reminded VA of my lay expertise in cardiology which helped me prove they misdiagnosed my husband-expertise the PA didn't have at all.

A real VA cardiologist ,in my opinion ,would have had no choice but to support the clinical record.

Then again I won for AO death due to complications of diabetes-the diagnosis of which never appeared at all in the med recs.For a VA doc to agree with the claim they would have had to expand on the prior malpractice that the VACO agreed on.

ANyone have more info on any reg that says PTSD or mental disability C & Ps cannot be released?

[darkhorse]

Me neither, never heard of having to wait until after the rating to get exam. Kind of defeats the purpose and this would benefit the VA since you can't correct any mistakes before they rate. Sometimes it can take months before they rate anyway.

I go to my VAMC and just sign a release. They then mail it to me. I also check to see if my shrink is in the office. If he is he usually will print it out right then and there. Guess it just depends on your relationship with your doctors.

DH

Cowgirl,

Who told you "been told myself mental health exams like Ptsd aren't releasable until after the rating"?

Please ask them under what authority the VA is going to deny vets access to evidence in their files. I don't mean the VARO said so, what law or regulation or FAST letter is the VARO standing on?

I am curious if this is just the VA blowing smoke up our skirts or if there has been some legal change to deny vets access to their Cfile information.

Thanks,

TS

[darkhorse]

The copy that's in your C-file is considered "administrative document." The one that's in your VAMC medical file is considered a "medical document."

When you request a copy of your c-file all you do is request it "in writing." Just a letter will do because it's considered "ADMIN."

If you want a copy from your medical file then you have to a "release of information" because it's condidered "MEDICAL."

Hence, the only difference in the medical and administrative aspect is where the document is located AND how it's used.

DH

Larry,

You bring up an interesting point about administrative records vs medical records but I don't know if it actually has any bearing on the question at hand since we, the vet, can request a copy of our administrative Cfile at any time in the process under the FOIA. Now, whether or not the VA sees fit to send it to us is another matter all together but getting a copy of your Cfile is a protected right that has no time limitations on it therefore, I do not understand why or how or under what regulation or point of law that they could deny a vet access to a copy of their Cfile (which is why I am asking anyone who is a part of this or has any knowledge of this practice to ask under what authority they are being denied access to information in their Cfile.

Part of the reason I think this may be smoke up our skirts is because when I was working my claim Pete was always telling us to get a copy of our C&P exam and Cfile. Well, I literally called 3 different times trying to get a copy of my C&P exam and everytime they said they didn't have it and I'd have to get it from the VARO. I didn't want to request my entire Cfile because I thought that would delay rating my claim and just wanted the C&P exam. Each time I'd call and be told no, I'd post on hadit and Pete would reiterate that I was allowed to have a copy of my C&P exam and I'd call the C&P exam center back.

Finally, in my last call, I got a "wrong" connection to out patient surgery and it was an old surg nurse who told me they didn't have it at the exam location because all med records were stored at the big hospital in another city. That the C&P exam site was a satellite station of the hospital and he even gave me their central number and told me to ask for medical records. I call the hospital, ask for med records and a guy immediately faxes me a request, I fax it back, and I have a copy of my C&P exam in my hands in less than 72 hours.

Point being, had I listened to the VA and not Pete, I would have probably given up after my first request and certainly after my second request but Pete was so adamant that I should be able to get a copy of my C&P exam that I kept at it until I got lucky and found out that the reason they were saying I couldn't have it was because they literally didn't have it themselves. Now why the med records folks at the exam site never bothered to tell me that and why it took a misconnection to out patient surgery for me to find out how to go about it is just ridiculous but it happened.

Long story short, just because the VA says they can't do something doesn't for one minute mean that's accurate.

I hope Kevin J and Cowgirl can get to the bottom of this in case it is a new wave of hassle the VA has in store for vets.

Thanks,

TS

Edited September 12, 2009 by darkhorse (see edit history)

[tssnave]

James,

Regarding your comment "Yeah. Hell, I'm "the enemy" here...." I would like to go on record and let you know that in the past I have found having a VA rater on the board to be a big help. When I was working my claim a couple of years ago, both MEDDAC and ENTROPENT were on and off the board. They, too, are VA insiders and posted answers to my questions on the board and in PM. Their explanations were especially helpful when I was spinning out of control (bipolar and VA claims processing do not a good combination make) and ready to completely lose it.

You can do a lot of good here on hadit and so long as you remain true to your mission of actually helping vets and doing right by us, then you are not the enemy - you are more a covert operator behind enemy lines.

Look, I am not trying to bash the VA, and I know it sounds like that, but in round 1 of my claim the VA ignored SMR evidence as well as letters (yes, plural) from the shrinks who treated me on active duty and denied sc. My vet rep said "sorry for ya." I got pissed, hung up on the vet rep, and called back a few days latter and talked to the supervisor and he said we'd do a NOD for sc.

Got hooked into hadit and got a clue so knew to ask for my C&P exam after I had one (read my other posts to find out what a hassle it was to get it - and I only pursued it because Pete was so adamant about it). The C&P examiner clearly stated my bp was continuous since treatment in the military 30 years ago, chronic/severe and went on to write a very clear statement of 100% soc/occ disability and cited my unemployability.

What did the VA do with that? Rate me 50% stating it didn't affect my ability to function independently even though the C&P exam said "yes" to that question and went on to list the ADLs that were impacted. I spend several thousand bucks on a good IMO from a shrink who does contract work for SS and he said that even SS doesn't ignore the evidence from their own examiners.

I get 100% P&T on the second appeal but what a headache and hassle and I won't bother to bore you with the many manic episodes I had during the process due to the stress. I was in Army admin and we always worked the regs to the benefit of the soldier so to see the VA blatantly ignore their own regs was a real slap in the face to me.

I do not trust the VA as an institution but I do value the hard work of honest VA employees who will read and apply the regulations on behalf of the veterans. That's all any of us want - a fair and honest evaluation of our claim.

So, back on point, I appreciate anything you can do to help vets on hadit and if there's a directive to not give PTSD vets their C&P exams please post a copy of the Fast letter or whatever it is they're using to deny vets their right to review evidence.

Thanks for being on the board.

TS Snave

Edited September 12, 2009 by tssnave (see edit history)

[blanco63]

You got my curiosity going. I've been here for several years and don't think I've seen anyone find Hadit that wasn't looking for claims advice. I am assuming from your post that you know way more than anyone else and didn't come here looking for advice. But, I'm confused about that too. Three increases in a year, yet to hear you tell it I'd have thought you would have gotten it right the first time. And did I read that right, you still have an open claim? That just seems odd for a person with your insight into the VA system.

I did get it right the first time. I got out in 1983 and filed a claim in june, 2008 for a physical disorder and got 0% service connection. i think it is a big deal to get serv conn after 25 years. By june, 2009, i had gone from 0 to 10 to 30 to 50%, three reconsiderations = three increases. 50% is the highest % you can get for that disorder. So, i tell myself that i have a good system and be your own vso and tell others in another post but i all i hear is get a vso, dro and appeals are the way to go, so go ahead. So in june, i filed a new claim for a mental disorder and had a c&p in july. Anyday now, i expect service connection with 0 to 100%. If i do not receive 100% this first time, i know i will have it by next june from just doing recons. So, back to the topic, if you want your c&p exam results, go to the vamc or write them not the ro, and lo and behold, what's that in my mailbox, wow, it's my c&p results.

[darkhorse]

Your situation went smoothly but it's different for every disabled vet and each claim is different. recons may have worked for you but may not work for others since each claim is different. Don't judge how everyone else needs to conduct their business just according to how it worked for you. Again, I'm happy for you and I want you to get everything you deserve. Just keep your mind open that appeals, DRO reviews, vso's do work for some when a reconsideration wouldn't be effective.

Humble yourself a little and think outside the box.

DH

I did get it right the first time. I got out in 1983 and filed a claim in june, 2008 for a physical disorder and got 0% service connection. i think it is a big deal to get serv conn after 25 years. By june, 2009, i had gone from 0 to 10 to 30 to 50%, three reconsiderations = three increases. 50% is the highest % you can get for that disorder. So, i tell myself that i have a good system and be your own vso and tell others in another post but i all i hear is get a vso, dro and appeals are the way to go, so go ahead. So in june, i filed a new claim for a mental disorder and had a c&p in july. Anyday now, i expect service connection with 0 to 100%. If i do not receive 100% this first time, i know i will have it by next june from just doing recons. So, back to the topic, if you want your c&p exam results, go to the vamc or write them not the ro, and lo and behold, what's that in my mailbox, wow, it's my c&p results.

[Kevin J]

Whats pretty messed up about the whole thing is in the same office on another wall they have this big sign with all the freedom of information act on it. I even pointed out that sign and asked how can a regional office supersede the federal law written right behind them. They looked dumbfounded and agreed that my argument makes sense but still would not do anything. When I asked for my records I didn't ask specifically for my C&P results but from a specific date 2 weeks prior, knowing that they have that policy. When the office worker was pulling the file up she was going down the line on the computer saying "OK, here, here, this, oops cant report that its a C&P", they do have access to that file at the VAMC, but just kept pointing to the sign on the wall about the regional office denying that report. My next visit I will be escalting this problem through proper channels via patient advocate office and see where it goes from there.

Thanks, for all the replies, and help. If anyone else in the Orlando area has an open claim see what your results would be trying to access your C&P.

[Kevin J]

Whats pretty messed up about the whole thing is in the same office on another wall they have this big sign with all the freedom of information act on it. I even pointed out that sign and asked how can a regional office supersede the federal law written right behind them. They looked dumbfounded and agreed that my argument makes sense but still would not do anything. When I asked for my records I didn't ask specifically for my C&P results but from a specific date 2 weeks prior, knowing that they have that policy. When the office worker was pulling the file up she was going down the line on the computer saying "OK, here, here, this, oops cant report that its a C&P", they do have access to that file at the VAMC, but just kept pointing to the sign on the wall about the regional office denying that report. My next visit I will be escalting this problem through proper channels via patient advocate office and see where it goes from there.

Thanks, for all the replies, and help. If anyone else in the Orlando area has an open claim see what your results would be trying to access your C&P.

BTW it wasn't Mental Health records just normal back stuff.

[Pete53]

Appeal the decision and ask for a Hearing. They will cave