g. Notifying the Claimant When VA’s Reasonable Efforts to Obtain Records Are Unsuccessful Notify the claimant that VA has not received requested records if reasonable efforts have been made to obtain relevant non-Federal records, but some or all of them have not been received, and a follow-up request for them is being made. Notify the claimant at the time of the follow-up request for the records, and identify the records that were not obtained briefly explain the efforts made to obtain the records, and describe any further action that will be taken with respect to the claim including processing the claim based on the evidence of record. Note: If neither Federal nor non-Federal records have been received within their respective response periods, notice about the status of both requests may be included in a single letter, but the letter must clearly differentiate between the actions we will take concerning these two categories of records. h. VA’s Responsibility for Requesting Medical Records VA must request relevant medical records from all sources that the claimant adequately identifies for the development of claims. Continued on next page 6. Requesting Non-Federal or Private Records, Continued i. Identifying Medical Records Request that the claimant identify the type of record being obtained custodian of the record and his/her address medical condition to which these records relate approximate time frame covered by these records, and complete a medical release, if necessary. Note: These requirements apply to all types of non-Federal records.
c. When to Request a Medical Opinion Versus an Examination A medical opinion versus an examination should be requested when only the following is necessary to decide the claim: reconciliation of different diagnoses opinion concerning the relationship between two conditions etiology and nexus opinions cases (that is, when the issue is whether a service-connected condition has aggravated a non-service connected condition) independent medical opinions, and opinion regarding the extent to which service-connected disabilities affect the Veteran’s ability to perform physical and non-physical tasks in order for VA to determine whether the Veteran is unemployable. Notes: Many opinion requests require information that would be gleaned as part of the normal examination process, which the physician should not be precluded from conducting, if necessary. A medical opinion is not generally required when service connection may be granted under because the disability is chronic, or symptoms that began in service have continued after the Veteran’s discharge. Generally, do not request a medical opinion to determine whether a disability causes a specific functional impairment, such as loss of use of an extremity; in such cases, an examination and description of the impairment and remaining function should suffice. References: For more information on requesting examinations, see , and medical opinions, see . Continued on next page 7. Requesting a Medical Opinion or Examination, Continued d. Stating Medical Opinion Requests Clearly When seeking a medical opinion follow the instructions in be very clear about what information or opinion is being requested send the following to the medical examiner: the claims folder, and the opinion request, and direct the medical examiner to review the claims folder, and provide a rationale for any opinion.
e. What the Medical Opinion Request Must Contain When requesting a medical opinion clearly state the nature of the opinion required explain why the opinion is needed, if this would clarify the request, and use a neutral and unbiased tone that gives no indication VA prefers one outcome over another or one specific answer over another. When requesting an opinion in compliance with BVA remand instructions, do not simply refer the examiner to the claims folder containing the remand instructions; explain what you are requesting or quote the instructions from BVA on the medical opinion request. Reference: For more information on obtaining evidence in an impartial manner, see , 23 Vet.App. 19, 24, 25-26 (2009). Continued on next page 7. Requesting a Medical Opinion or Examination, Continued f. Importance of Identifying Evidence Relevant to the Medical Opinion Request The requester should identify the available evidence to assist the physician in focusing his/her review. The evidence should be tagged in the claims folder, but the examiner must be advised that he/she is not limited to reviewing only this evidence. Note: Avoid the potential problem of steering the examiner to review only the evidence pre-selected as relevant since a medical professional may have a differing opinion as to what evidence is relevant and must not be limited in the record review. The identification of the evidence must include a general description of it, indicating the source approximate dates, and subject matter.