ptsd Need Some Sound Advice

[qwiksting]

I am trying to get some information about the VA mental health Drs' ability to fill out a required form that my company requires for medical disability. Can they and would they fill out this form? It is from the state of Florida. I do not recieve any medical from outside the VA, and the form is required to be filled out by the treating physician. I am 70% ptsd. I have a letter from my employer stating that I have become somewhat of a liability. They gave me the paperwork to give to my doctor. The risk management department brought me in last week and said that the side effects of my medication (ptsd), which makes me tired and drowsy is what they are worried about because my job requires driving.

[carlie]

I am trying to get some information about the VA mental health Drs' ability to fill out a required form that my company requires for medical disability. Can they and would they fill out this form? It is from the state of Florida. I do not recieve any medical from outside the VA, and the form is required to be filled out by the treating physician. I am 70% ptsd. I have a letter from my employer stating that I have become somewhat of a liability. They gave me the paperwork to give to my doctor. The risk management department brought me in last week and said that the side effects of my medication (ptsd), which makes me tired and drowsy is what they are worried about because my job requires driving.

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.

. 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, 2013HA 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 HA 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

[qwiksting]

Thank you carlie, I didnt know if my PCP or mental health doc could sign those forms for me.