Medical Records to Support FDC VIRGINIA A. WIMMER, SMSgt (Ret) CVSO, San Joaquin County Good morning. Y’all know how I like to facilitate these discussions. It is not about me teaching any of you anything new. This is not about me trying to tell you something about something that you don’t already know. This is about reconnecting and reemploying those tools and techniques that you already know and have used but may have forgotten, or perhaps have fallen by the way side. For those of you who know it all already I’d just ask that you back me up here and share your vast knowledge with my other colleagues who are interested in hearing this briefing. I will tell you that I got the idea to do this when Mr. Jolly sent out email to remind us that NPRC, VA, and DoD were getting creative with archiving service medical records.

GOAL The goal in any claim is to get the information in front of the decision-maker you want considered to achieve the desired outcome. The VA will only consider the evidence they are aware of and can obtain. Any effort you can make to assist in this endeavor will help your client and the decision-maker.

What Is a Fully Developed Claim? The Fully Developed Claims (FDC) program is an initiative that offers Veterans and survivors faster decisions from VA on compensation, pension, and survivor benefit claims. Veterans and survivors must submit all medical evidence and/or relevant records in their possession, and those records which are easily obtainable, such as private medical records, at the time they make their claim and certify that they have no further evidence to submit.

Types of Fully Developed Claims There are many types of claims that can be considered fully developed. For example, if you're filing a VA claim for the very first time, you have an original claim. A reopened claim means you have new and material evidence and you want VA to reconsider a claim that was previously denied. There are also new claims, secondary claims, and special claims. In any of these cases, Veterans and survivors must submit all medical evidence and/or relevant records in their possession, and those records which are easily obtainable, such as private medical records, at the time they make their claim and certify that they have no further evidence to submit for FDC. 1 year appeal period has not yet expired) [M21-1 Part III.iii.2.F.1.a].

VA and FEDERAL MEDICAL EVIDENCE VA is required to obtain all Federal records that they are aware of and that could be used in deciding a FDC In order for VA to obtain these records, VA must know where and when the veteran received treatment through the VA Medical Center (VAMC), Federal Institution, or military hospital There is no presumption that because a veteran lives in a catchment area of a VAMC that he/she received treatment there, and VA is not obliged to look for records that they are not aware of

How Do I Obtain These Records? Obtaining medical records or sufficient medical evidence to support a claim is not difficult. Obtaining medical records or other supportive evidence may be time consuming but not difficult. Determine what medical evidence is needed. Determine where the medical evidence is held/housed/archived or from where to request the information. VA, Private Medical Facility, Military or Federal Treatment Facility Determine the correct form to request the medical evidence SF 180, DD 2870, VA 21-4142, VA 10-5345, or other Release of Medical Information Form (ROI)

What Did You Say About ITF & 21-22? You should always prepare a 21-0966 and a 21-22 It may take 30 to 90 days to collect all of the relevant medical evidence to support the FDC Save the date of claim for the first time you meet with the client Let the client know that gathering medical evidence to support the claim is a time consuming exercise The Intent To File and POA will preserve the date of claim until ALL the evidence and the completed claim for benefits can be sent to the VA

What Form Do I Use? SF 180 is used to request information from National Personnel Records Center (NPRC) and all DoD departments in possession of these records VA 21-4142 and 21-4142a is used to request records from Veterans Centers and from civilian medical providers to be used in conjunction with a FDC VA 10-5345 is a medical release of information form used to release information, records, complete DBQ, request a “NEXUS” from a VA provider or from within the VHA ROI—{Release of Medical Information Form} Specific ROI forms may be required by civilian or non-federal medical providers or facilities} DD 2870 is used to request medical information from a military treatment facility although the SF 180 will suffice; this form should rarely be used by VSO’s

I Know! But What Form Do I Use? SF 180 is used to request information from NPRC and/or DoD Service medical records or Service Treatment Records (STR) to include inpatient medical records and surgical reports Military personnel records which can include DD 214s/Separation Documents, and most other service personnel records found within the Official Military Personnel File Use the version in VetPro Refer to the handout titled: “Medical Records Location” or SF 180

Ok! But How Do I Use the SF 180? SF 180 (Rev. 11/2015) Request Pertaining to Military Records – this is the latest version First determine which branch of service the Veteran was last discharged from Then determine the date of the veteran’s last active duty discharge date Then determine which records you are seeking to request

This form is not complicated…it is imperative that you, the claimant, or veteran completes the form in its entirety though. Section I: Full name, full social security number, full date of birth, and place birth (if known). Please select one or more components of service, be advised if you are requesting reserve component records from NPRC you wont get any! But you may use this form to send to the Guard or Reserve unit. It is important to fully indicate the dates of service DAY MONTH YEAR. Specify the last honorable period of active duty service. You want to be sure to indicate whether enlisted or officer (I’ve never had a form returned for not indicating enlisted or officer but why take a chance?) Section II: you must determine what records you wish to receive, DD 214 and medical records or just one or the other. You may request them both. Your request may be delayed but do what is best for you and the client at the time. The VA is still responsible for verifying service dates…so if you only need a DD 214 just request that or if you need medical records to substantiate your FDC please request both at the same time. Indicate why you need the records “benefits” should be sufficient or my favorite “other: continuity of medical care”. Section III: Please be sure to fully complete this section, you must indicate who is requesting the records, their relationship to the veteran, a complete name and address, signature – MANDATORY SIGNATURE, date, phone number, and/or fax number if available and an email address if available.

x Ok, so this is a completed form for a deceased veteran whose spouse is requesting records and DD 214. This SF 180 must be accompanied by a Death Certificate. Remember this form is subject to the privacy act. Regardless there must be ample information to identify the veteran, name, DOB, branch of service, service dates, and type of records being requested also…you must absolutely have a signature. THERE MUST BE A SIGNATURE. No signature not documents! Certain identifying information is necessary to determine the location of an individual's record of military service. Answer each item on the SF 180. If you do not have and cannot obtain the information for an item, show "NA," meaning the information is "not available". Include as much of the requested information as you can. Incomplete information may delay response time. To determine where to mail this request see Page 2 of the SF180 for record locations and facility addresses. NPRC can research certain documents with enough information. Because of the fire in 1973 approximately 16-18 million Official Military Personnel Files (OMPF) were destroyed .

Ok I think I got it! Case Study: The veteran was discharged from the USCG on 07/30/1999. Where are her medical records located or archived? What form would you use to request her medical records? Where are her military personnel records and DD 214 located? How would you request her DD 214?

That Was Too Easy! Give Me Another One! Case Study: A CA Air National Guard service member died on active duty during Operation Iraqi Freedom on 10/30/2002. Where are her medical records located or archived? How would you request her medical records? Where are her military personnel records and DD 214 archived? How would you request her DD 214?

Ok I Definitely Got This Now! Case Study: Navy Senior Chief Petty Officer retired after 24 years of faithful and honorable service on 04/01/2016 and now resides in San Diego California with his lovely wife and two kids. He has been working as DoD contractor overseas since he retired from the Navy. The Senior Chief was visiting with his friend and mentor, Pat of Napa CA and has finally decided to file a claim for VA disability. Where are his medical records located? How would you request his medical records based on where they are located? Where are his personnel records and DD 214 archived? How would you request his DD 214? Who is authorized to sign the requests for copies of any of these records?

Last One, For Real This Time! Case Study: The wife of a US Marine Corps Captain, requests copies of her husband’s service medical records because he works too much and doesn’t have time to come to the VSO. The Marine was discharged after 4 years of honorable service on 02/28/2014. Where are his medical records located? How would you request his medical records based on where they are located? Where are his personnel records and DD 214 archived? How would you request his DD 214? Who is authorized to sign the requests for copies of any of these records?

Ok Let’s Move On To help expedite FDC, VA will request expedited assistance from VA Medical Centers (VAMC), Government providers of records (excluding Guard or Reserve units), and any other Federal organizations that assist or provide information to VA You as the professionally accredited veterans service representative must tell the VA where those records are located You must clearly state the name of the facility and the location Example: VAMC Martinez, Martinez CA May 2012- July 2016 Brook Army Medical Center, Fort Sam Houston 1999- present. OR you must send all records along with the claim if you have them and only when you have ALL of them

VA and FEDERAL MEDICAL EVIDENCE VA is required to obtain all Federal records that they are aware of and that could be used in deciding a FDC In order for VA to obtain these records, VA must know where and when the veteran received treatment through the VA, Federal Institutions, or military hospital There is no presumption that because a veteran lives in a catchment area of a VA Medical Center (VAMC) that he/she received treatment there, and VA is not obliged to look for records that they are not aware of

What Is The Best Form To Use? Military Service Records – SF Form 180, is the best form to use to request copies of military records Service Treatment Records Service Personnel Records DD 214 or Military Discharge Record/Certificate Civilian Medical Record – VA Form 21-4142/4142a You may have to send a 21-4138 You may have to also send the “proprietary” ROI as well DO NOT EVER SEND A COPY OF 21-4142 to VBA, unless you do not want the claim considered for FDC process ROI form as required by the civilian medical provider Veterans Center Records– VA Form 21-4142/4142a is the preferred request Although a letter from VBA with the veteran’s signed informed consent will suffice

What Form Do I Use For VA Contract Records? VA 21-4142 and 21-4142a Requests for records from civilian treatment facilities If the veteran received treatment through a private physician under VA contract, it is not likely that the record of that treatment would be in the veteran’s electronic record at the VA Medical Center. It would more likely be a paper record as VA does not give contract physicians access to the VA electronic record. Any doctor who holds these records will not release them without a HIPAA compliant release statement signed by the person to whom the records pertain.

Ok I Definitely Got It All Now! Get ALL the medical information in front of the decision-maker to support the FDC Know how to request the information Know where to request the information from Send it ALL at once with the claim to avoid being ejected from the FDC process Don’t send negative or unsupportive information to VBA VA is required to obtain all Federal records that they are aware of and that could be used in deciding a FDC Obtaining medical records or other supportive evidence may be time consuming but not difficult Complete the medical request forms in their entirety

WRAP UP Identify the evidence the veteran needs to have considered in his/her FULLY DEVELOPED CLAIM --FDC Get the full name and address of the source of these records Have the veteran sign a release form sufficient to have those records released to the VA Include information (dates and places of treatment including the address of non-VA sources) of any Federal records the veteran knows about that are relevant to the FDC Impress upon the client that they are ultimately responsible for furnishing any non-Federal records in connection with their FDC

FINALLY SHE IS DONE THANK YOU IMPORTANT FAX NUMBERS National Personnel Records Center Fax # (314) 801-9049 National Personnel Records Center Fax # BURIAL (314) 801-0764 National Personnel Records Center Fax # HOMELESS (314) 801-9195 Department of VA, Records Management Center Fax # (314) 679-3615 THANK YOU