ptsd Ptsd/mst Denial

[lp56]

After two long years, I just received a denial and the SOC from the VARO for service connected ptsd due to MST and I am absolutely sick about it. I really need help on where to turn now because I want to continue to fight this, but it seems like no matter what evidence I submit, service connection for PTSD due to MST is almost impossible to achieve. The SOC I received stated that "You have submitted copies of emails, letters, journals entries and documents from the Army indicating evidence of military sexual trauma. Based on all the evidence received, we have conceded that you did suffer from military sexual trauma during your military service. Treatment reports from VAMC/Outpatient Clinic show you have received treatment for PTSD symptoms and for major depressive disorder. VA examination dated on February 14, 2012, states you have a diagnosis of PTSD and dysthymia disorder. The examiner provides the opinion that she cannot say with confidence that your military sexual trauma experiences meet criteria A for PTSD. The examiner also states she cannot resolve that the issue of PTSD is a result of your military experience without resort to mere speculation. Service connection for PTSD remains denied. Although we conceded that you were exposed to traumatic events during your military service, to include military sexual trauma, we have not received any medical evidence that your PTSD is the result of your military sexual trauma. We have requested 2 different VA examinations, with 2 different examiners and both have been unable to provide a medical opinion that your PTSD is the result of your military sexual trauma. The treatment reports from the Outpatient clinic show you have received treatment for PTSD symptoms associated with your history of military sexual trauma. However, these reports do not provide a medical opinion and rationale that your PTDS is due to military sexual trauma, and the result of other trauma."

My MH doctor specifically told me her medical notes were more vague due to my privacy, so If I asked her to write a medical opinion and rationale that my PTSD is due to MST, would this help? Should I go to a civilian MH doctor to gain another opinion?

I was sent a Form 9 and must state why I think the VA decided my case incorrectly. Is it time for a lawyer? I didn't received much help from the VFW due to the VSOs lack of experience and uncomfortableness with MST. I am trying to find records from an outpatient base clinic in Hawaii which will show pregnancy test, STD test and other sickness from the timeframe of MST. It seems the VA wants to link PTSD to me witnessing molestation of daughter almost 15 years after MST instead of all that happened during active duty. Can anyone PLEASE advise me? I feel so hurt, betrayed and now even angry, especially that the VA conceded that I was exposed to MST during my military service. My original post on Hadit was under the PTSD Disorder Claim and was called PTSD/MST Denial as well, but this seems to be a more suitable area to post now.

[lp56]

After almost 6 years of appealing my claim for PTSD due to MST, I finally received a favorable BVA decision today.  Nothing in the paperwork I received tells me what happens next, except that my file will be returned to my VARO and that I'll be getting a survey call about my experience with the BVA. I can't bear the thought of yet another C&P exam, but is that the next step to getting a rating? My last exam was in 2012. Does the VARO get ticked off when their ruling is overturned by the BVA? WIll they try and rate me low starting off so I have to keep appealing over and over? This battle feels far from over. I really want to feel good (or great) about this BVA win, but since I have no idea of what happens next, I feel more anxious and stressed instead of feeling happy and relieved. As usual, thank you in advance for any information, advice or encouraging words about what happens next.

[lp56]

Thank you Dot09. I will post my win in the success topic and I will certainly research the P&T option. To me, the CaP exams were always the worst triggers because neither of my examiners were the least bit sensitive to how they were damaging me even further.

[Army Soldier]

I suffered a MST in 1989 and reported it to CQ who in turn went back and told the drill Sargent who retaliated against me.  I never spoke about the event for 30 years.  At the time I didn't know it was MST or what PTSD was.  I recently went through a 90 day PTSD program.  I filed for my VA benefits for PTSD, general anxiety and depression and was denied because I didn't have any evidence.  I was told to get support letters and resubmit.  I have 7 support letters now.  Has anyone else experienced this and if so what did you do to get a rating.  I'm confused and don't know what to do. Any feedback would be appreciated.  Thanks.

[Rattler]

This one is for Carlie. DO NOT believe what they tell you about you VA doctor / mental health provider not being able to fill out a DBQ for you this is the new VHA DIRECTIVE that says they can do that and more. It over rules any local directives that may say different. This is a current directive as of this post.

1134(2)_D_2016-11-28-Provision of Medical Statements & Completion of Forms by VA Health Care Providers, 11PC - Primary Care.pdf

Edited May 28, 2021 by Rattler767 (see edit history)

[broncovet]

Here is the deal. You must have these 3 things for Service connection:

1. Current diagnosis. No disease now, no benefits.

2. An in service event.

3. A "nexus" or link between the two.

It would appear you are missing a medical nexus, or that you have an "unfavorable" nexus. It sounds like you have a current diagnosis of PTSD, and you have an "in service" event.

Now, you want to read over your C and P exams, to see if one or both of these stated something very close to "The Veterans PTSD is at least as likely as not related to ........event which happened in military service". (This is the nexus statement you are lacking).

If the docs did say something like this, then you need to file a NOD and dispute the denial, citing the docs nexus.

If the docs did not say something like this, you need to find another doc who will, or you wont get service connection. You can try your VAMC..swithch docs, if you have to, and see if another doc their will be more "Veteran friendly" and give you your nexus that you so desperately need. A doc (or other qualified medical professional) has to give the nexus.

To obtain SC, you need to get the nexus. If I recall, the VA does not accept IMO's from private docs for PTSD nexus. It has to be a VA doc. But, please check that out. You just have to persist until you get your nexus statement.

Remember, if the doc already gave the nexus, which you can find out by reading your medical records, then you simply need to appeal and cite the doc and the date he opined your PTSD/MST was at least as likely as not caused by MST in service.

[lp56]

Today I went and requested my MH records for the past year and the two C&P exams I had. I already have 2 of the past 3 years of medical records, but I really need to go through them line by line now. At one time my doctor asked me if I was applying for disability, but at the time I just told her I was trying to get better. The doctor stated that she would write her notes differently if I were applying for SC disability. She also stated that she writes her notes a little more vague to protect the patient's privacy in case someone reads them. The VA doctor I was seeing for 3 years recently transferred from the local VA clinic to the VA hospital that is an hour away. I know I can call or write her and ask for the nexus because she talked about it all the time. The focus of my therapy was always on the MST I suffered while I was on active duty.

In Dec 2011, I did a NOD and was granted a DRO hearing which I thought went very well. That is how I got a second C&P exam. I had another traumatic event in my life 15 years after the service and although I did talk about it because it involved my ex, that was never the focus of my therapy. I am sure my former VA doctor will write the nexus statement, but does it have to be part of my medical records or can she just send it to me? Once I get the nexus statement, do I still need to fill out the Form 9 and follow the BVA route or can I request the RO look at the new evidence again and reconsider their denial? I know I have to address the SOC and I can waive the RO consideration of additional evidence, but isn't the BVA appeal process another 2 or 3 years of waiting? Maybe there isn't a choice anymore on how I proceed next. I think I am going to seek an experienced VA appeal lawyer, especially with MST if that's possible. I tried the VSO route, but he was worthless and almost detrimental to me during my DRO hearing. I really appreciate the input and I am feeling a little better about what I am missing because I am quite confident that I can obtain the nexus statement based on my therapy history and my doctor's treatment of PTSD due to MST.

[john999]

If you are getting an IMO your doctor needs to review your SMR's and current medical records.

[lp56]

So when I request my doctor (who has been treating me for the past three years) write a nexus letter, are you saying I should send her my SMR As well so she can review them? I don't have too many service records, but I am in process of finding outpatient records from a clinic on base where I was stationed at in HI. My current medical records are comprised mainly of this same doctor's treatment notes for the past three years. I am rereading these same medical records to see if my doctor was specific in connecting my current diagnosis of PTSD to my in-service MST. How well are current medical records scrutinized by the VA for a medical nexus? I submitted 2 years worth of medical records (weekly therapy sessions) as evidence, so there is a lot of paperwork to go through. Thank you for your advice.

[lp56]

I went through my VA medical records today and I did not see what appeared to be a PTSD/MST nexus. All my treatment notes referred to MST and PTSD, but no actual nexus statement linking the two together. However, I wrote my treating MH physician today and explained my SC PTSD claim was denied and why. I also told her I was appealing the VARO's decision. I included my SMRs with my request to her, as John999 advised, so she could review them. She already has access to my current medical records, especially since most of the records comprise medical notes from her. On my SOC, I noticed that the VARO still had the VSO that dumped me as my POA. I sent the VARO another request to revoke that POA, especially since I am considering using a lawyer for this appeal.

If I receive a nexus letter from my doctor, can I request another personal hearing at the VARO in order to submit any new additional evidence for consideration before it goes to the Board of Veterans Appeals? If so, do I need to still submit a VA Form 9 within the 60 days to make it clear I want to appeal the denial? I have to agree with Broncovet about the nexus letter being the only thing I am missing. If I knew for sure the nexus letter was the only thing missing, I don't know that I would use a lawyer just yet. However, I am almost scared not to have some type of representative on my side, especially when it comes to filing out the VA Form 9 correctly. I plan to request a hearing from the BVA via teleconference on my Form 9, but I would love the VARO to reconsider my claim before it goes to the BVA based on the new evidence (medical nexus letter) I present them. Maybe this is all wishful thinking, but the appeals deadline clock is ticking for whatever I need to do.

[peacecindia]

Get a lawyer.

My lawyer told VA they are in err.

I'd never know if they were in err or not personally.

I run on on my gut instincts and VA feels adversarial to me most of the time.

That's why I got a lawyer.

I got tired of their judgmental and rude attitude.

[carlie]

I went through my VA medical records today and I did not see what appeared to be a PTSD/MST nexus. All my treatment notes referred to MST and PTSD, but no actual nexus statement linking the two together. However, I wrote my treating MH physician today and explained my SC PTSD claim was denied and why. I also told her I was appealing the VARO's decision. I included my SMRs with my request to her, as John999 advised, so she could review them. She already has access to my current medical records, especially since most of the records comprise medical notes from her. On my SOC, I noticed that the VARO still had the VSO that dumped me as my POA. I sent the VARO another request to revoke that POA, especially since I am considering using a lawyer for this appeal.

If I receive a nexus letter from my doctor, can I request another personal hearing at the VARO in order to submit any new additional evidence for consideration before it goes to the Board of Veterans Appeals? If so, do I need to still submit a VA Form 9 within the 60 days to make it clear I want to appeal the denial? I have to agree with Broncovet about the nexus letter being the only thing I am missing. If I knew for sure the nexus letter was the only thing missing, I don't know that I would use a lawyer just yet. However, I am almost scared not to have some type of representative on my side, especially when it comes to filing out the VA Form 9 correctly. I plan to request a hearing from the BVA via teleconference on my Form 9, but I would love the VARO to reconsider my claim before it goes to the BVA based on the new evidence (medical nexus letter) I present them. Maybe this is all wishful thinking, but the appeals deadline clock is ticking for whatever I need to do.

If you get an IMO stating your PTSD is at least as likely as not

a result of / related to your active duty sexual trauma,

submit it to your VARO and request they reconsider the claim

based on this new evidence.

Watch your one year clock to NOD and don't let the time pass if this is

your current situation.

[Ethan'sGrandma]

lp56,

Your post does not make clear what kind of timeframe you were given for appeal, but you do mention a 60 day time for form 9, so I'm surmising that's what you were given? Whatever is the time limit, please make sure you do not miss it. Otherwise, the VA can turn around and deny you so quick if you miss their deadline, even if their error. It happened to me, so would hate to see it happen to someone else. I sent in my form 9 in time, overnight expressed it, actually, signed for at VARO, but I received a notice of claim closed due to no response. It was a good thing I had my copy of receipt, or I'd be out of luck. Meanwhile, I do hope you were able to obtain the medical opinion from your provider...

[lp56]

lp56,

Your post does not make clear what kind of timeframe you were given for appeal, but you do mention a 60 day time for form 9, so I'm surmising that's what you were given? Whatever is the time limit, please make sure you do not miss it. Otherwise, the VA can turn around and deny you so quick if you miss their deadline, even if their error. It happened to me, so would hate to see it happen to someone else. I sent in my form 9 in time, overnight expressed it, actually, signed for at VARO, but I received a notice of claim closed due to no response. It was a good thing I had my copy of receipt, or I'd be out of luck. Meanwhile, I do hope you were able to obtain the medical opinion from your provider...

My VA psychologist, a MST coordinator, told me she couldn't write a medical opinion because she only "treats" PTSD. Talk about feeling betrayed by someone I finally trusted to open up to and help me. I point blank asked her if my ptsd was due to mst or not and she said YES it was. She said she was very sorry, she knows it is frustrating and she would talk to her supervisor about it. She said she couldn't add any more to my records than she already did, which are very detailed indeed. My appeal is to the BVA and that's where the 60 day timeframe comes in. I got help from a new state veteran service rep and have already filed the necessary Form 9, with additional evidence. I feel crushed right now, but I am not giving up. Maybe my VA psychiatrist won't be afraid or cop out when it comes to giving an opinion. Time will tell while I wait for my BVA hearing. Edited January 11, 2013 by lp56 (see edit history)

[carlie]

My VA psychologist, a MST coordinator, told me she couldn't write a medical opinion because she only "treats" PTSD. Talk about feeling betrayed by someone I finally trusted to open up to and help me. I point blank asked her if my ptsd was due to mst or not and she said YES it was. She said she was very sorry, she knows it is frustrating and she would talk to her supervisor about it. She said she couldn't add any more to my records than she already did, which are very detailed indeed. My appeal is to the BVA and that's where the 60 day timeframe comes in. I got help from a new state veteran service rep and have already filed the necessary Form 9, with additional evidence. I feel crushed right now, but I am not giving up. Maybe my VA psychiatrist won't be afraid or cop out when it comes to giving an opinion. Time will tell while I wait for my BVA hearing.

Well print this out and take it to your provider !

http://www1.va.gov/vhapublications/ViewPublication.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, 2013VHA 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

Process Flow C hart

for Non-VA Forms.pdf

[lp56]

Well print this out and take it to your provider !

http://www1.va.gov/vhapublications/ViewPublication.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, 2013VHA 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

Process Flow C hart

for Non-VA Forms.pdf

Well print this out and take it to your provider !

http://www1.va.gov/vhapublications/ViewPublication.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, 2013VHA 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

Process Flow C hart

for Non-VA Forms.pdf

Thank you so very much Carlie. I thought it was so wrong that my own VA doctor wouldn't honor my request for her medical opinion reagarding my PTSD due to MST after treating me for 3 years. If I am reading 4d(2) of this directive correctly, my doctor must place a descriptive statement in my medical record regarding my current status of existing medical condition, disease, or injury, including prognosis and degree of function since I requested it. This statement may then be requested by VBA for the purposes of making a claim determination.

For my appeal, can the VBA request my doctor to provide a medical opinion on my condition, especially since I have a letter showing that I asked for one? I don't hold much hope that my doctor will write an opinion, especially since she told me she couldn't add anything in my records that wasn't already there.