VA Form 21-4142 is of record but a VA Form 21-4142a is not develop to the claimant by telephone and record any PHP/Vet Center source information provided by the claimant on VA Form 21-4142a, or if unable to reach the claimant via telephone, generate a development letter to the claimant through MAP-D requesting the return of a completed VA Form 21-4142a, and create a custom development action titled in MAP-D or VBMS. Important: If developing for a release for Vet Center records, users must alter the generated text to inform the claimant the form is needed for Vet Center records. VA Form 21-4142a is of record but a VA Form 21-4142 is not generate a development letter to the claimant through MAP-D requesting the return of a completed VA Form 21-4142, and create a custom development action titled in MAP-D or VBMS. Important: If developing for a release for Vet Center records, users must alter the generated text to inform the claimant the form is needed for Vet Center records. both VA Forms and 21-4142a are of record, and have not been processed by PMR contractor follow the instructions in M21-1, Part III, Subpart iii, 1.C.5.f for development of the claimant’s PMRs. Exception: Claims filed with the San Juan and Manila ROs should be processed as noted in the instructions in M21-1, Part III, Subpart iii, 1.C.3.e. both VA Forms 21-4142 and 21-4142a are not of record generate a development letter to the claimant through MAP-D to complete, sign, date and return both forms, and create a custom development action titled in MAP-D or VBMS. Important: If developing for a release for Vet Center records, users must alter the generated text to inform the claimant of the form needed for Vet Center records. Notes: If PHP source information is obtained from the claimant by telephone and recorded on VA Form 21-4142a, follow the instructions in M21-1, Part III,
Subpart iii, 1.C.5.f for development of the claimant’s PMRs. If the claimant fails to respond to the request for additional information, no further action to request the claimant’s PMRs is required. The is utilizing a contractor to provide development assistance by attempting to retrieve all PMRs that Veterans and their dependents have identified on the VA Form 21-4142a. The PMR contractor will not request Vet Center records. References: For more information on requesting Vet Center records, see M21-1, Part III, Subpart iii, 1.C.4.h exceptions regarding versions of VA Form 21-4142, see M21-1, Part III, Subpart iii, 1.C.3.b, and the PMR program, see M21-1, Part III, Subpart iii, 1.C.5. e. Procedure for Requesting Medical Records For Non-PMR Program ROs Follow the steps in the table below to request medical records from sources other than VA. Important: These procedures apply only to ROs not participating in the PMR Program. Step Action 1 Prepare and send a request for any medical records that the claimant has identified, and are relevant to his/her claim. Attach to the original letter VA Form 21-4142, signed by the claimant, and an extra copy of the letter. Advise the custodian of the records that VA cannot pay for records it requests. Note: When creating the letter in MAP-D, select the Private Treatment Records 15-Day Notification – Provider paragraph, or VBMS, select the Notice – VA Is Contacting Provider for Med Rcds letter. 2 Notify the claimant that VA made the request, and he/she is ultimately responsible for ensuring VA receives the records. 3 Establish a suspense date that expires 15 days from the current date. 4 Did VA receive the records it requested within 15 days? If yes,
them to VA. the medical care provider requires a VA Form 21-4142 with an original signature, and the VA Form 21-4142 in the claims folder has an original signature make a photocopy of the VA Form 21-4142 (with the original signature) and retain it in the claims folder send the medical care provider a letter containing the paragraphs labeled in MAP-D: Private treatment records – 15-day notification – Provider, or in VBMS: Initial Private 3rd Party Letter, and VA Form 21-4142 (with the original signature) notify the claimant of the action taken, and allow 15 days for a response. Note: At the end of the response period, route the claim to the rating activity as soon as all other development is complete, regardless of whether or not the medical care provider responded. the medical care provider requires a VA Form 21-4142 with an original signature, and the VA Form 21-4142 in the claims folder does not have an original signature, or the claimant has an electronic claims folder (eFolder) instead of a claims folder prepare a letter containing the paragraphs labeled Private treatment records – 15-day notification – Claimant change the time limit for responding to the letter to 30 days send the letter to the claimant, and allow 30 days for a response. Notes: If the claimant fails to respond to the request for private medical records within 30 days, route his/her claim to the rating activity as soon as all other development is complete. If the claimant returns VA Form 21-4142 to VA with an original signature instead of obtaining the records him/herself, follow the instructions in M21-1, Part III, Subpart iii, 1.C.3.e. If VA is processing the
corresponding claim in a paperless environment, the claimant must send the form directly to the medical care provider, or obtain the records and submit them to VA. g. Claimant Notification When PMRs Are Unavailable As noted in M21-1, Part I, 1.C.5.a, VA must notify the claimant of its inability to obtain relevant private treatment records identified by the claimant. Follow the steps in the table below, when attempts to obtain the private treatment records are unsuccessful. Important: The RO must follow these steps to notify the claimant regardless of whether the records were requested by the PMR Program contractor or the RO. Step Action 1 The decision maker must free text the following into the Evidence section of the rating decision. Private Medical Records (PMR) requested from [name of provider], but not received. 2 If using the Automated Decision Letter (ADL) process, the VSR must ensure the unavailable records are listed in the Evidence Considered section of the decision notice. If generating the decision notice through Personal Computer Generated Letters (PCGL), the VSR must ensure the rating decision with the free texted evidence from Step 2 is attached to the decision notice. References: For more information on the Evidence section of the rating decision, see M21-1, Part III, Subpart iv, 6.C.4, and decision notices, see M21-1, Part III, Subpart v, 2.B. h. General Information About HIPAA The HIPAA Privacy Rule protects all "individually identifiable health information" held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. The Privacy Rule calls this information protected health information (PHI). PHI includes the individual’s past and present physical or mental health condition(s), and the health care provided to the individual.
Part III, Subpart iii, 3.A. 4. Obtaining VA Medical Records Introduction This topic contains information on obtaining VA medical records, including definition of VA medical records requirement to obtain VA medical records concluding VA medical records do not exist means for obtaining VA medical records conducting an enterprise search in CAPRI selecting and storing electronic VA medical records actions taken when an RO is unable to obtain relevant VA medical records, and obtaining records from a Vet Center. Change Date March 10, 2016 a. Definition: VA Medical Records VA medical records include records documenting inpatient and outpatient treatment received at a Veterans Health Administration (VHA) facility, or by a contractor under the Veterans Choice Program, and Vet Center records. References: For more information on means for obtaining VA medical records, see M21-1, Part III, Subpart iii, 1.C.4.d obtaining records from a Vet Center, see M21-1, Part III, Subpart iii, 1.C.4.h, and Veterans Choice program, see . b. Requirement to Obtain VA Medical Records When relevant treatment is alleged at a VA facility, ROs must attempt to obtain the records, unless the RO concludes that it is reasonably certain the records do not exist. Important: If the claimant does not indicate treatment at a VAMC or provide dates of treatment, ROs must perform the enterprise search in CAPRI as described in M21-1, Part III, Subpart iii, 1.C.4.e, and associate any relevant treatment records into the Veteran’s claims folder. When a Veteran alleges VA treatment, but no records are found in either
Step Action 1 Close out the tracked item, if relevant, using the date the RO determined the records do not exist or are irretrievable as the close-out date. Prepare a VA Form 27-0820 that contains the following a statement by the VSR certifying that relevant medical records at [insert name of VAMC] for the period [insert date range of treatment] do not exist the VSR’s name and title, and the date the VSR completed the form. Place the VA Form 27-0820 in the claims folder or upload it into the claimant’s eFolder. 2 The decision maker must free text the following into the evidence section of the rating decision: We have been unable to obtain records from [insert name of VAMC] for the period [insert date range of treatment]. We have determined that these records do not exist. We will now make a decision based on the evidence of record. 3 If using the ADL process, the VSR must ensure the unavailable records are listed in the Evidence Considered section of the decision notice. If generating the decision notice through PCGL, the VSR must ensure the rating decision with the free texted evidence from Step 2 is attached to the decision notice. References: For more information on the notice of inability to obtain Federal records, see M21-1, Part I, 1.C.5.b the Evidence section of the rating decision, see M21-1, Part III, Subpart iv, 6.C.4, and decision notices, see M21-1, Part III, Subpart v, 2.B. h. Obtaining Records From a Vet Center Vet Center medical records are considered Federal records in VA’s constructive custody. These records are not retrievable through CAPRI because the Vet Center provides mental health services that are protected under HIPAA. When a Veteran has been treated at a Vet Center, ROs must obtain a completed VA Form 21-4142 and VA Form 21-4142a follow the steps for Federal records development outlined in M21-1 Part III, Subpart iii, 1.C.2.b, and send the final-attempt letter shown in M21-1, Part III, Subpart iii, 1.C.2.e when Vet Center records are unobtainable. Important: Do not take any additional action if the claimant does not authorize the release of the Vet Center records.
sexually transmitted diseases rape, and abuse. The RO must take note of the following when developing for health care records from an MTF. Only use VA Form 21-8359 when submitting a request for the claimant’s health care records that do not pertain to a sensitive diagnosis. Use a VA Form 21-8359 and VA Forms 21-4142 and 21-4142a signed by the individual who is the subject of the information, when requesting health care treatment records that pertain to a sensitive diagnosis. Request nothing other than the items listed under Part II of the first page of VA Form 21-8359. Do not request interim or special reports from a hospital until after the Veteran has discharged. If the MTF responds that the records have been retired, ROs must attempt to obtain the records from NPRC. References: For more information on how to locate an MTF, see requesting MTF clinical records from NPRC, see M21-1, Part III, Subpart iii, 2.A.2.c, and locating inpatient MTF clinical records, see M21-1, Part III, Subpart iii, 2.B.3.d. 9. Action To Take Upon Receipt of Medical Evidence From an MTF Introduction This topic contains information on the action to take upon receipt of medical evidence from an MTF, including accepting medical evidence from an MTF as an informal claim prior to March 24, 2015 when to undertake additional development, and handling a notice of discharge after assigning a 100-percent disability rating under . Change Date January 29, 2016
a. Expenses Associated With Services the Department of State Provides The Department of State generally provides services through consular officers at American embassies and consulates, including investigation in foreign countries, without cost to VA. The Department of State informs VA if an expense will be incurred. b. Services Consular Officers May Provide Consular officers may furnish general information and assistance, including assistance to claimants, beneficiaries, and apportionees, in the preparation of applications for benefits inspect and approve institutions for pursuit of courses of study by children between the ages of 18 and 23 investigate and develop claims at VA’s request and perform other services in connection with a claim administer oaths for VA purposes take action at the request of the Under Secretary for Benefits (USB) or his/her designee on matters involving guardianship, and make arrangements for physical examinations. Reference: For more information on ROs that are responsible for processing foreign claims and contacting the consular officers, see M21-1, Part III, Subpart iii, 1.C.11.c.