Filing A Form 4138 To Request Another Exam

[slangpdx]

I got a copy of my exam and it is full of distortions, omissions and mistatements. I have an appointment with my rep tomorrow to file a request for another exam. Does anyone have experience with this or can suggest the best approach?

[pacmanx1]

You may need an IMO(Independent Medical Opinion) or a Medical Evaluation if you can get one from your primary care provider to refute what the C & P doctor said. You can use a civilian or VA primary care provider, just a doctor that knows you and have treated you.

Edited April 29, 2010 by pacmanx1

[Bigdan]

Slangpdx,Did they already give you a rating on the C & P Exam? If they did you need to file a Notice Of Disagreement within 30 days of the date of the Rating and send it Certified Returned receipt back to VBA. Also as Pete992 said you may need an IMO from an outside physician concerning the PTSD and that it is service connected. If you can get this from a Mental Health Professional it would be better! Try to get a letter from from your family, friends, co-workers and anyone that knows about your mental medical problem. Documentation is the key on PTSD. I hope this helps you out some.BigDan.

[cowgirl]

Good advice on the responses. Recommend checking with a VA social behavorial health provider, they have tools to diagnose and care for those with PTSD. Also Service Medical Records aren't everything when it comes to PTSD and most often I hear vets were never diagnosed in service for PTSD, hence the 'post' for P-TSD. This condition doesn't usually appear overnight.

Encourage you to continue to read about other PTSD claims work by using Hadit search feature, something may strike a bell for you as well.

Best to ya,

Cowgirl

[pacmanx1]

Bigdan

Slangpdx,Did they already give you a rating on the C & P Exam? If they did you need to file a Notice Of Disagreement within 30 days of the date of the Rating and send it Certified Returned receipt back to VBA. Also as Pete992 said you may need an IMO from an outside physician concerning the PTSD and that it is service connected. If you can get this from a Mental Health Professional it would be better! Try to get a letter from from your family, friends, co-workers and anyone that knows about your mental medical problem. Documentation is the key on PTSD. I hope this helps you out some.BigDan.

I disagree, if a veteran is denied service connection for any claim and then gets new evidence within 30 days or so, as long as it is not close to the year dead line I would send VA a request for reconsideration based on new evidence and wait to file the NOD. It could be possible that the veteran could get his/her claim approved based on that evidence instead of just filing a NOD. When a veteran files a NOD, that is the beginning start of an appeal and VA likes appeals to go to BVA instead of reviewing the evidence. A veteran is normally given a rubber stamp denial without VA even looking at the new evidence. So I would try the request for reconsideration first then file the NOD. A request for reconsideration "should" take no more than 90 to 120 days and if the claim is denied the veteran can still file a NOD as long as he/she is within a year of the rating.

I do agree in this case that a Mental Health Professionals' (Medical opinion) would hold more weight since the problem is PTSD, Sorry I did not check before I posted

Hope this makes sense

As Always Hope the Best

Edited April 30, 2010 by pacmanx1

[john999]

I also advise an IMO. You may get another c&p exam and it could be worse. I did as a result of an appeal of a biased exam. The next exam was even worse. The IMO's did the trick. The c&p was done by a resident. My IMO was done by a MD with 30 years experience.

[Bigdan]

According the the following VHA Directive 2008-071 - VA Doctors should help the Veteran with his disability paperwork. After being treated since the mid-70's by VA Doctors they generally are lazy and don't want to do the work!See the VHA Directive:Department of Veterans AffairsVHA DIRECTIVE 2008-071Veterans Health AdministrationWashington, DC 20420October 29, 2008PROVISION OF MEDICAL STATEMENTS AND COMPLETION OF FORMS BY VA HEALTH CARE PROVIDERS1. 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, 2013VHA DIRECTIVE 2008-071October 29, 20082(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.(:D 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 fromVHA DIRECTIVE 2008-071October 29, 20083recording 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. REFERENCEa. 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 expiresOctober 31, 2013.Michael J. Kussman, MD, MS, MACPUnder Secretary for HealthDISTRIBUTION:CO:E-mailed 10/30/08FLD:VISN, MA, DO, OC, OCRO, and 200 – E-mailed 10/30/08VHA DIRECTIVE 2008-071October 29, 2008A-1ATTACHMENT ASUGGESTED ALGORITHM THAT MAY BE USED IN ESTABLISHINGLOCAL PROCEDURES f