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vperl

Va Dr. Statements ?

Question

Is there a policy that VA Dr. or PA's cannot give written statements to Veterans hunting and asking for proof of a valid VA Disability claim.

I have had both my VA PA and my Cardiac Doctor seem very hesitant to write a statement that I could use in my AO IHD presumptive claim.

What is going on, or is it a case by case decision made by the different Medical people at the VA.. with no policy for or against writing a supporting claim statement.

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I'm curious too, no Docs that I have seen would go on record for just about anything.......

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If you have a documented diagnosis of IHD and if you were in Vietnam during the War-you have a presumptive claim under the AO regulations.

Why do you feel you need a VA medical statement to support the claim?

AO exposure by service in Vietnam and any disability on the presumptive list (or getting there such as IHD) equals AO SC comp unless the VA could somehow medically attribute the AO disablity to something else.

They usually never even attempt to do that.

My biggest concern about IHD is that-if the vet had a long history of smoking and a doctor said that contributed to their IHD-could the VA possibly deny the AO etiology for the claim?

Then again how could they (VA) possibly infer that IHD in a AO exposed vet is NOT from AO even if there are other risk factors?

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Is there a policy that VA Dr. or PA's cannot give written statements to Veterans hunting and asking for proof of a valid VA Disability claim.

I have had both my VA PA and my Cardiac Doctor seem very hesitant to write a statement that I could use in my AO IHD presumptive claim.

What is going on, or is it a case by case decision made by the different Medical people at the VA.. with no policy for or against writing a supporting claim statement.

vperl,

It took me a bit but I finally found this for you.

I could not copy & paste this in the same format you will get at the link.

This format just all runs together - so try the link as it is much more clear.

Hope this helps a vet.

carlie

http://www1.va.gov/vhapublications/ViewPub...asp?pub_ID=1790

Department of Veterans Affairs

VHA DIRECTIVE 2008-071

Veterans Health Administration

Washington, DC 20420

October 29, 2008

PROVISION OF MEDICAL STATEMENTS AND COMPLETION OF FORMS BY VA HEALTH CARE PROVIDERS

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) by providing the veteran patients with medical statements with respect to their medical condition(s) and functionality. NOTE: Attachment A identifies a process to assist VHA providers in honoring requests by veterans to complete those forms.

2. BACKGROUND: VHA strives to be the provider of choice for all 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). 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); clinicians must honor all requests for the provision of medical statements, following procedures established by the local facility Release of Information (ROI) Office.

4. ACTION: Each medical facility Director is responsible for establishing and implementing a 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.

(1) Although the primary care provider typically receives the form from the veteran, when completion of the form extends beyond the scope of the primary care provider, additional input from appropriate specialty services may be considered (e.g., functional assessments from Physical Medicine and Rehabilitation (PM&R), Occupational Therapy, etc.). 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.

THIS VHA DIRECTIVE EXPIRES OCTOBER 31, 2013

VHA DIRECTIVE 2008-071

October 29, 2008

2

(2) 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, and local procedures must be followed for obtaining this authorization. Examples of these non-VA forms include, but are not limited to:

(a) Family Medical Leave Act forms.

(b) Life insurance application forms.

© Non-VA disability retirement forms.

(d) State workers’ compensation forms.

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

(f) Social Security Administration (SSA) examination 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, that includes a statement of diagnosis, prognosis, and assessment of function for purposes other than VA disability claims.

(1) The veteran must sign VA Form 10-5345a, and then be responsible for forwarding the veteran's own information to the requesting entity.

(2) 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. ROI 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 disability ratings 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

VHA DIRECTIVE 2008-071

October 29, 2008

3

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; however, 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.

5. REFERENCE

a. VHA Handbook, 1605.1.

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

6. FOLLOW-UP RESPONSIBILITY: The Office of Primary Care, Patient Care Services (11PC) is responsible for the contents of this Directive. Questions may be addressed to 202-461-7182.

7. RECISSIONS: VHA Directive 2007-024 is rescinded. This VHA Directive expires

October 31, 2013.

Michael J. Kussman, MD, MS, MACP

Under Secretary for Health

DISTRIBUTION:

CO:

E-mailed 10/30/08

FLD:

VISN, MA, DO, OC, OCRO, and 200 – E-mailed 10/30/08

VHA DIRECTIVE 2008-071

October 29, 2008

A-1

ATTACHMENT A

SUGGESTED ALGORITHM THAT MAY BE USED IN ESTABLISHING

LOCAL PROCEDURES f

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Well, I have been told it is a lock and that with the complications I have, a 100% ought to pop up.....

But, you'd have to go to that C&P with me to explain the way the exam went....

The NP seemed to want all sorts of NEW proof, I had a MUGA within 2 weeks and he seemed not impressed.

He claimed he never read my two letters from two Private Doctors that had been treating me for 10 years....

Like the letters just went bye bye.....

I am going on that I over reacted, till the results are in, sometime in 2011.

&&&&&&&&&&&&&&&&&&&&&&&&

If you have a documented diagnosis of IHD and if you were in Vietnam during the War-you have a presumptive claim under the AO regulations.

Why do you feel you need a VA medical statement to support the claim?

AO exposure by service in Vietnam and any disability on the presumptive list (or getting there such as IHD) equals AO SC comp unless the VA could somehow medically attribute the AO disability to something else.

They usually never even attempt to do that.

My biggest concern about IHD is that-if the vet had a long history of smoking and a doctor said that contributed to their IHD-could the VA possibly deny the AO etiology for the claim?

Then again how could they (VA) possibly infer that IHD in a AO exposed vet is NOT from AO even if there are other risk factors?

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Is there a policy that VA Dr. or PA's cannot give written statements to Veterans hunting and asking for proof of a valid VA Disability claim.

I have had both my VA PA and my Cardiac Doctor seem very hesitant to write a statement that I could use in my AO IHD presumptive claim.

What is going on, or is it a case by case decision made by the different Medical people at the VA.. with no policy for or against writing a supporting claim statement.

great info Carlie, Im pretty sure that info is going to help me a lot, hope I helps vpearl too. Thanks

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