Many VA doctors tell Veterans that they do not allowed to fill out non-VA disability forms. That is simply wrong, and it violates VA policy. If you have a Social Security Disability or Long Term Disability Insurance Form, you can take it to your VA doctors – primary care and specialists – and expect them to fill it out. VA actually passed a policy requiring this in 2007, and then amended it in 2008 to make it even plainer for their doctors. VHA DIRECTIVE 2008-071 — PROVISION OF MEDICAL STATEMENTS AND COMPLETION OF FORMS BY VA HEALTH CARE PROVIDERS describes what VA doctors have to do, as well as you have to do get a non-VA form filled out. You have to complete VA Form 10-5345a, Individuals Request for a Copy of Their Own Health Information, but there is little more that you have to do other than present your non-VA disability form to the doctor to complete.
I put the full text of the directive below, but I recommend you go the online link for DIRECTIVE 2008-071 — PROVISION OF MEDICAL STATEMENTS AND COMPLETION OF FORMS BY VA HEALTH CARE PROVIDERS and print a copy. Take it with you when you go the your VA doctor with the form for your Social Security Disability or Long Term Disability case. If they refuse to fill out your form, show them the Directive. If that does not work, ask for the supervisor in the department
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) 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.
(c) 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
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.
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
John V. Tucker is a Disability Attorney who helps people nationwide in claims for Social Security Disability, Long Term Disability, ERISA Disability, and VA Disability benefits. For a free consultation, call toll free (866) 282-5260.