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M21-1, Part III, Subpart iii, Chapter 1, Section C – Requesting Evidence From Federal Record Custodians

Overview


In This Section
 
This section contains the following topics:
Topic
Topic Name
1
2
3
4

1.  General Information on Requests for Federal Records

 


Introduction

This topic contains general information on requests for Federal records, including

Change Date

November 2, 2018

III.iii.1.C.1.a. VA’s Responsibility to Assist Claimants in Obtaining Evidence

The Department of Veterans Affairs (VA) assists claimants in establishing entitlement to benefits by making reasonable efforts to obtain evidence needed to support a claim, whether that evidence is held by a Federal or non-Federal entity.
References:  For more information on

III.iii.1.C.1.b.  Standard Procedure for Requesting Records From a Federal Entity

The table below describes the standard procedure for requesting records from a Federal entity.  This includes requests for records from
  • service departments
  • the Social Security Administration (SSA) via fax or mail
  • the Office of Workers’ Compensation
  • Vet Centers, and
  • the National Personnel Records Center (NPRC) and if necessary, the Office of Personnel Management (OPM), when Federal civilian employment records are needed.
Exception:  The procedure described in the table below is not for application in the situations described in M21-1, Part III, Subpart iii, 1.C.1.c.
Important:
  • The procedure described in the table below represents the minimumefforts VA must make in order to comply with the duty-to-assist requirements in 38 CFR 3.159.  If there is a reasonable expectation that development actions beyond those described in the table below could result in the procurement of records to support a pending claim, such additional actions should be taken.
  • If VA obtains the records at any point in this procedure
    • stop taking the steps described in the table below, and
    • decide the claim after all other development actions are complete.
  • Requests for records held by a Federal entity require priority handling under the circumstances described in M21-1, Part III, Subpart iii, 2.I.1. When priority handling is required, flag the corresponding claims folder at the development stage.
  • NPRC has specific requirements that individuals and third parties must follow to request Federal civilian employment records.  Instructions are located on the Official Personnel Folders, Federal (non-archival) Holdings and Access website.
  • NPRC may not be able to provide all civilian employment information identified on VA Form 21-4192, Request for Employment Information in Connection With Claim for Disability Benefits.  NPRC will provide available information and instruct claims processors to request the remaining information from OPM.
  • Faxing or mailing a request for records to SSA is only permitted when the SSA- Government-to-Government Services Online (SSA-GSO) interface is down for an extended period, as indicated in M21-1, Part III, Subpart iii, 3.A.2.c.
Step
Action
1
Send a request for Federal records to the appropriate records custodian. Ask the custodian to respond within 30 days.
Reference:  For assistance in determining the location of service records, see M21-1, Part III, Subpart iii, 2.A and B.
2
Determine if a response has been received from the records custodian and follow the instructions in the table below.
If the records custodian …
Then …
provided all of the requested records
no further actions described in this block are required.
  • provided some but notall of the requested records, or
  • did not respond
proceed to Step 4.
responded but did not provide the requested records
proceed to the next step.
3
Follow the instructions in the table below when the records custodian responded but did not provide the requested records.
If the records custodian …
Then …
indicates the records exist but are located at a different facility
return to Step 1.
indicates
  • the records exist at a different facility, and
  • the custodian forwarded VA’s request to that facility
proceed to Step 4 and make the follow-up request referenced in that step to the facility to which the records custodian forwarded VA’s request.
Important:  Do not allow the facility another 30 days to respond before taking the action described in Step 4.
indicates the records exist but are temporarily unavailable to VA
  • ask the records custodian for the date on which the records should be available, and
  • proceed to Step 4 after that date.
states
  • the records VA requested are not in the custodian’s possession, and
  • the custodian does not expect to receive them
4
Make a follow-up request for the records.  Ask the records custodian to respond within 15 days.
Important:  Attempt to make the follow-up request by telephone. If telephone contact cannot be made, mail the follow-up request to the records custodian.
5
Was telephone contact made with the records custodian in Step 4?
  • If yes,
  • If no,
    • document the action taken in a Veterans Benefits Management System (VBMS) or a Modern Award Processing – Development note, and
    • proceed to Step 7.
6
Did the records custodian indicate the requested records had already been shipped or would soon be shipped to VA?
  • If yes, proceed to the next step.
  • If no, return to Step 3.
7
Did VA receive records from the records custodian after making the follow-up request?
  • If yes, return to Step 2.
  • If no, proceed to the next step.
8
Prepare a final notification letter using the Letter Creator tool, or prepare an equivalent notice using Personal Computer Generated Letters (PCGL).
Exception:  For documenting the unavailability of VA records, seeM21-1, Part III, Subpart iii, 1.C.2.l.
References:  For more information on

III.iii.1.C.1.c.  Situations in Which the Standard Procedure for Requesting Records From a Federal Entity Is Not Applicable

The procedure described in the table in M21-1, Part III, Subpart iii, 1.C.1.b is notfor application if the Federal records VA is seeking are
  • VA medical center (VAMC) records
    • accessible electronically through the Compensation and Pension Record Exchange (CAPRI), and/or
    • being obtained via a VA Form 10-7131, Exchange of Beneficiary Information and Request for Administrative Action, request
  • records VA routinely requests through
    • the Personnel Information Exchange System (PIES)
    • e-mails to the Records Management Center (RMC)
    • the Defense Personnel Records Information Retrieval System (DPRIS), and
    • the SSA-GSO interface, or
  • service treatment records (STRs) available in the Joint Legacy Viewer (JLV).
References:  For more informaiton on

III.iii.1.C.1.d.  Requests for Medical Records From SSA

VA may request copies of the medical records on which SSA based its decision upon, if there is an indication the
  • claimant has filed a claim for or is receiving disability benefits from SSA, and
  • medical records may be pertinent to his/her claim for
    • increased disability compensation
    • a 100-percent disability rating based on individual unemployability (IU)
    • disability pension, or
    • additional benefits based on being housebound or requiring the aid and attendance of another person.
References:  For more information on

III.iii.1.C.1.e.  Final Notification to Claimants That VA is Unable to Obtain Relevant Federal Records

If efforts to obtain records from a Federal entity are ultimately unsuccessful, regional offices (ROs) must
  • prepare a final notification letter using the Letter Creator tool, or prepare an equivalent notice using PCGL, and
  • send the letter to the claimant.
Exceptions:  If the unavailable Federal records are
  • STRs, the RO must first attempt to locate the records in JLV before sending the final notification letter
  • VAMC or VR&E records, the RO must follow the instructions in M21-1, Part III, Subpart iii, 1.C.2.l, or
  • fire-related records, and the Veteran fails to provide enough information to submit a request to reconstruct the records via PIES, follow the procedures in M21-1, Part III, Subpart iii, 2.E.1.c or f, whichever is applicable, instead of sending the final notification letter.
Important:  All claims processors can prepare final notification letters for any type of Federal record.
References:  For more information on

 2.  Obtaining VA Medical and VR&E Records

Introduction

This topic contains information on obtaining VA medical and VR&E records, including

Change Date

November 2, 2018

III.iii.1.C.2.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 Veteran’s Choice Program, and
  • Vet Center records.
References:  For more information on

III.iii.1.C.2.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
References:  For more information on

III.iii.1.C.2.c. Electronic Recordkeeping of Treatment at VAMCs

VHA completed the transition to electronic recordkeeping at all VAMCs in late 2004.  VHA employees access requests for Veteran health records using the Automated Medical Information Exchange (AMIE) program.
Veterans Benefits Administration (VBA) claims processors access the electronic health records using CAPRI and VistA Imaging Advanced Web Image Viewer (AWIV) Web application.  Treatment that occurred prior to the transition to electronic recordkeeping has been archived by VHA, therefore claims processors should always consider submitting a VA Form 10-7131 request for archived records when treatment is alleged at a VAMC prior to 2005.
CAPRI can also be used to locate information about when the Veteran first applied for care by VA, as well as when the Veteran enrolled for care at specific VAMCs.
  • The registration date is the date the Veteran applied for VA healthcare and predates the enrollment system. This date applies to all VAMCs and is not unique to each individual facility.
  • The enrollment date is the date the Veteran was entered into the specific VAMC’s computer system and is unique for each VAMC the Veteran visited.  Enrollment date-tracking was implemented in 1996.
Important:  When communicating with VHA employees regarding electronic treatment records, be mindful that AMIE is the tool used by VHA to access and view and electronic VA Form 10-7131 requests.  The employees may not understand references to CAPRI.
Note:  To find the registration or enrollment date for a specific VAMC
  • log into that VAMC through CAPRI
  • input the Veteran’s identifying information, and
  • click on the REPORTS tab, and from the menu displayed on the left side of the screen, select
    • VIEW REGISTRATION DATA, scroll down the displayed report to the APPLICATION INFORMATION field, and
    • PATIENT PROFILE MAS (Full), scroll down the displayed report to the ENROLLMENTS field.
References:  For more information on

III.iii.1.C.2.d.  Means for Obtaining VA Medical Records

The table below describes the means for obtaining VA medical records pertaining to the claimed conditions.
If …
Then …
an RO receives notice that a Veteran has been admitted to a VA medical facility
request/retrieve any necessary reports or hospital summaries through CAPRI.
Note:  Users may request/retrieve progress notes or hospital summaries for a range of dates through CAPRI.
  • a Veteran received treatment under VHA’s Veterans Choice Program from a contracted healthcare provider, and
  • a summary of that treatment is relevant to a pending claim
obtain the relevant records through theAWIV Web Application.
an RO receives notice that a Veteran has been admitted to a non-VA medical facility that provides services under a VA contract

 

retrieve any necessary reports or hospital summaries through the AWIV Web application.
If records in AWIV are not inclusive, contact the contracted facility to request a complete copy of the Veteran’s treatment records.
  • a Veteran has received treatment at a VAMC and/or outpatient clinic, and
  • a summary of that treatment is relevant to a pending claim
request/retrieve a summary of treatment through CAPRI dating one year prior to the date of claim (DOC) and/or any other dates indicated by the claimant as relevant to the claim.
Note:  If images were created as part of the Veteran’s treatment at the VA facility, ROs must attempt to access these images through the AWIV Web Application.
  • a Veteran’s
    • treatment occurredbefore 2005, and
    • VA medical records are not electronically accessible through CAPRI or AWIV, and
  • the RO determines relevant records likely exist

Exception:  If evidence in the electronic record provides credible evidence that treatment records from 2005 or latershould exist, a VA Form 10-7131request may be submitted.   The request must

  • provide explicit detail why the records are presumed to exist, and
  • what efforts were undertaken to obtain them prior to submitting the request.
  • submit an electronic VA Form 10-7131 request in CAPRI that
    • includes the dates of treatment in the REMARKS section, and
    • checks the OTHER/EXAM (REVIEW/REMARKS) box, and
  • follow procedures outlined inM21-1, Part III, Subpart iii, 1.C.2.f when following-up on the record requests.
Important:  If the attempts to obtain the records are unsuccessful, follow the documentation procedures in M21-1, Part III, Subpart iii, 1.C.2.l.
a Veteran received treatment at a Vet Center
a Veteran does not identify treatment at a specific VAMC
Notes:
  • Establish necessary controls to ensure the return of the requested reports.
  • If the identified VAMC records are available entirely in CAPRI or AWIV, it is not necessary to create a tracked item to confirm that the records have been uploaded directly into the electronic claims folder (eFolder).
  • The RO must associate any record pertaining to the claimed condition that is
    • recent treatment dated within a year of the DOC, and
    • treatment identified by the claimant that is relevant to the pending claim.
  • The RO must associate the recent and relevant records to the eFolder when
    • development action is first being taken on the claim, or
    • if no development action is necessary, before the routing the claim for rating activity review and consideration.
  • The rating activity is responsible for
    • a final review of CAPRI and JLV to ensure all recent and relevant records have been associated with the eFolder
    • associating additional records that have been identified during the final review, and
    • ensuring the records are appropriately documented in the decision.
References:  For more information about

III.iii.1.C.2.e.  Determining Whether a VA Form 10-7131 Should be Submitted

When a Veteran alleges VA treatment, but no records are found in either CAPRI or AWIV, the RO must then determine whether
  • the records exist, but are inaccessible through CAPRI or AWIV and require a VA Form 10-7131 request to obtain the records, or
  • it is reasonably certain the records do not exist.
Factors to consider when determining whether a VA Form 10-7131 should be submitted for records that are not available in CAPRI or AWIV include:
  • whether the treatment occurred prior to
    • full implementation of electronic record-keeping, and/or
    • the registration and enrollment date shown in CAPRI
  • if there is evidence of treatment at a VAMC during the identified time period in
    • CAPRI, and/or
    • the claims folder
  • responses to prior VA Form 10-7131 requests, and
  • if the records are relevant to the claim.
If … And … Then a VA Form 10-7131request  …
the Veteran indicates treatment started prior to 1996 the registration date is blank orbefore the date the Veteran indicates treatment started is required for the period from the date the Veteran indicates treatment started, to

  • the end of treatment, or
  • the date when electronic records first became available at the VAMC, whichever is earlier.
the registration date is after the date the Veteran indicates treatment started is required for the period from the registration date to

  • the end of treatment, or
  • the date when electronic records first became available at the VAMC, whichever is earlier.
the Veteran indicates treatment started between 1996 and 2005
  • the registration date isblank or before the date the Veteran indicates treatment started, and
  • the enrollment date isblank or before the date the Veteran indicates treatment
is required for the period from the date the Veteran indicates treatment started to

  • the end of treatment, or
  • the date when electronic records first became available at the VAMC, whichever is earlier.
  • the registration date isblank or before the date the Veteran indicates treatment started, and
  • the enrollment date isafter the date the Veteran indicates treatment
is required for the period from the enrollment date to

  • the end of treatment, or
  • the date when electronic records first became available at the VAMC, whichever is earlier.
the registration date is after the date the Veteran indicates treatment is required for the period from the registration date to

  • the end of treatment, or
  • the date when electronic records first became available at the VAMC, whichever is earlier.
the Veteran indicates treatment started during, or after 2005
should not be submitted.  If the records are not available electronically, claims processors may assume they do not exist.
Exception:  If evidence in the electronic record provides credible evidence the records should exist, aVA Form 10-7131 request may be submitted, as indicated in M21-1, Part III, Subpart iii, 1.C.2.d.
Important:
  • When evidence in the claims folder contradicts the information displayed in CAPRI, always base the request off the information provided by the Veteran and what is available in the claims folder.
  • Do not submit a VA Form 10-7131request for records covering a period of treatment that has been previously requested, unless a response from VHA was not received.
Example:  A Veteran indicates treatment at Loma Linda VAMC from 1994 to present.  A review of CAPRI displays a registration date in 1997 and treatment beginning October 7, 2001.  The claims processor locates treatment records from Loma Linda VAMC in the claims folder for treatment from January 22, 1994, through December 31, 1995.  The information in the claims folder contradicts what is provided in CAPRI, therefore, the Veterans statement of treatment and the available evidence in the claims folder should dictate what records need to be requested.  Duplicate requests for treatment records should not be submitted; therefore, a VA Form 10-7131 request should be submitted for treatment from January 1, 1996, through October 6, 2001.
References:  For more information on

III.iii.1.C.2.f.  Checking the Status andFollowing Up on Electronic 10-7131 Requests

Follow the steps in the table below when checking the status or conducting a follow-up on an electronic VA Form 10-7131 request after the initial 30-day suspense period has expired and the records are not in the eFolder.
Step
Action
1
Review the inquiry and the information in the claims folder to ensure the request was accurate.
If the request …
Then …
  • was submitted in error, and/or
  • the information is not needed
  • submit a new VA Form 10-7131 request that
    • identifies the date the prior request was submitted, and
    • requests cancellation of the prior request without replacement
  • cancel the existing tracked item as an error, and
  • no further action in this table is necessary.
was sent to the wrong VAMC
  • submit a second VA Form 10-7131 request to the same VAMC that
    • identifies the date the prior request was submitted, and
    • requests cancellation of the prior request without replacement
  • cancel the existing tracked item (created for the incorrectVA Form 10-7131 request) as an error
  • submit a new VA Form 10-7131 request to the correct VAMC
  • add a tracked item to track the new request, and
  • conduct the follow-up review after the 30-day suspense expires on the new request.
  • was sent to the correct VAMC, and
  • the information in the request was incorrect
  • submit a new VA Form 10-7131 request that
    • identifies the date the prior request was submitted and requests cancellation of the prior request, and
    • includes the corrected details of the records being requested from the VAMC
  • cancel the existing tracked item (created for the incorrectVA Form 10-7131 request) as an error
  • add a tracked item to track the corrected request, and
  • conduct the follow-up review after the 30-day suspense expires.
was accurate
proceed to the next step.
2
Review the REMARKS section of the request.  Did the VAMC Release of Information (ROI) staff provide a status update or mark the request complete?
If …
Then …
the request was marked complete
proceed to the next step.
a status update was not provided
proceed to Step 4.
a status update was provided
  • update the tracked item to
    • indicate a follow-up has been conducted, and
    • advance the suspense period of 15 days, and
  • proceed to Step 10 after expiration of the 15-day suspense.
3
Review the REMARKS section to determine what action was taken by the ROI staff to complete the request.
If …
Then …
a negative response was provided
document the RO’s attempts to obtain the records as indicated inM21-1, Part III, Subpart iii, 1.C.2.l.
the records have been sent to the scanning vendor
advance the suspense period 10 days.  Repeat until the records are available.
the request indicates the records are
  • available electronically, or
  • were scanned by VHA
locate the scanned records in CAPRI or AWIV and associate with the claims folder.
Notes:
  • The date of treatment/entry date for historical records that are scanned into CAPRI or AWIV will typically be the last date of treatment in the date range provided by VBA.
  • Scanned historical records will often include “historical” in the name of the file/entry.
4
Attempt to follow-up with the ROI staff via a phone call at three different points during the day.
If contact is …
Then …
made
  • inform the ROI staff that this is VBA’s first follow-up attempt and ask for the records to be submitted within 15 days
  • document the phone call on VA Form 27-0820, and
  • proceed to Step 6.
Important:  As indicated in M21-1, Part III, Subpart iii, 1.C.2.c, VHA uses AMIE to access and view and electronic VA Form 10-7131requests that VBA submits using CAPRI.   Do not tell ROI staff that the request is available in CAPRI.
not made
  • send an encrypted e-mail to the VAMC’s local Health Information Management (HIM) Chief identified on the HIM roster.  The e-mail should
    • state that a VA Form 10-7131request is pending with the[insert VAMC name] ROI staff
    • state the Veteran’s name and last four digits of the social security number (SSN), and
    • request a status update, and
  • proceed to the next step.
Note:  Copies of e-mails sent to and received from the local VAMC HIM Chief need to be added to the claims folder.
5
  • Edit the VA Form 10-7131 request and at the top of the REMARKS section add the following statement:
[date remark is being added] – VBA conducting first follow-up attempt.  Please provide records within 15 days. [user’s initials]
  • click the CLOSE WINDOW button, and
  • save the changes.
6
  • Update the tracked item to
    • reflect the follow-up was completed, and
    • set the suspense for 15 days in the future, and
  • proceed to the next step after the expiration of the 15-day suspense.
7
Review the REMARKS section of the request.  Did the ROI staff provide a status update or mark the request complete?
If …
Then …
the request was marked complete
proceed to the next step.
a status update was not provided
proceed to Step 9.
a status update was provided
  • update the tracked item to
    • indicate a follow-up has been conducted, and
    • advance the suspense period of 10 days, and
  • proceed to Step 12 after expiration of the 10-day suspense.
8
Review the REMARKS section to determine what action was taken by the ROI staff to complete the request.
If …
Then …
a negative response was provided
document the RO’s attempts to obtain the records as indicated inM21-1, Part III, Subpart iii, 1.C.2.l.
the records have been sent to the scanning vendor
advance the suspense period 10 days.  Repeat until the records are available.
the request indicates the records are
  • available electronically, or
  • were scanned by VHA
locate the scanned records in CAPRI or AWIV and associate with the claims folder.
Notes:
  • The date of treatment/entry date for historical records that are scanned into CAPRI or AWIV will typically be the last date of treatment in the date range provided by VBA.
  • Scanned historical records will often include “historical” in the name of the file/entry.
9
Attempt to follow up with the ROI staff via a phone call at three different points during the day.
If contact is …
Then …
made
  • inform the ROI staff that this is VBA’s second follow-up attempt and ask for the records to be submitted within 10 days
  • document the phone call on VA Form 27-0820, and
  • proceed to Step 11.
Important:  As indicated in M21-1, Part III, Subpart iii, 1.C.2.c, VHA uses AMIE to access and view and electronic VA Form 10-7131requests that VBA submits using CAPRI.   Do not tell ROI staff that the request is available in CAPRI.
not made
  • send an encrypted e-mail to the VAMC’s local HIM Chief identified on the HIM roster.  The e-mail should
    • state that a VA Form 10-7131request is pending with the[insert VAMC name] ROI staff
    • state the Veteran’s name and last four digits of the SSN, and
    • request a status update, and
  • proceed to the next step.
Note:  Copies of e-mails sent to and received from the local VAMC HIM Chief need to be added to the claims folder.
10
  • Edit the VA Form 10-7131 request and at the top of the REMARKS section add the following statement:
[date remark is being added] – VBA conducting additional follow-up attempt.  Please provide records within 10 days.[user’s initials]
  • click the CLOSE WINDOW button, and
  • save the changes.
11
  • Update the tracked item to
    • reflect the follow-up was completed, and
    • set the suspense for 10 days in the future, and
  • proceed to the next step after the expiration of the 10-day suspense.
12
Repeat Step 7 (and subsequent steps, as necessary) until the records or a negative response has been received.   The VAMC HIM Chief does notneed to be contacted.
References:  For more information on

III.iii.1.C.2.g.  Conducting an Enterprise Search in CAPRI

When a Veteran does not identify treatment at a specific VA facility, ROs must
  • perform an enterprise search in CAPRI, and
  • associate any relevant records with the claims folder.
If the search results do not show any VAMC treatment add a permanent note to the appropriate claims processing system documenting the results.
References:  For more information on the

III.iii.1.C.2.h.  Selecting and Storing Electronic VA Medical Records

If medical evidence relevant to a pending issue is available electronically through CAPRI or AWIV, the records must be added to the claims folder.
A claims processor can create a single collection of pertinent medical records with the CAPRI Report Builder and save the selected records as a portable document format (PDF) document with Adobe PDF or MS Word and upload the records into VBMS Documents folder using the Upload Document function.
References:  For more information on

III.iii.1.C.2.iConcluding VA Medical Records Do Not Exist

ROs can reasonably conclude VA records do not exist when a Veteran indicates treatment at a VA facility
  • for a period earlier than his/her
    • registration date (if one is present), or
    • enrollment date (if one is present), when the indicated treatment began or after 1996
  • for a specific condition during a timeframe when other electronic records exist for the Veteran (and the records cannot be found electronically), or
  • if the attempts outlined in M21-1, Part III, Subpart iii, 1.C.2.df for records not electronically accessible in CAPRI/AWIV are unsuccessful.
Exception:  Do not conclude records are nonexistent without first attempting to obtain the records using VA Form 10-7131, when evidence in the claims folder contradicts the registration or enrollment information displayed in CAPRI.
Important:  Claims processors must consider the circumstances of the individual claim when making conclusions on whether records exist.  These may include, but are not limited to, the following considerations:
  • Electronic claim submission services require specific calendar start and end date when entering a date range for treatment.  The claimant may not have the ability to list a more general start and end period (month/year) for the treatment period.
  • Treatment for a disability does not always require continued evaluation and review on a weekly or monthly basis.  Gaps in treatment during a date range provided by the claimant should be expected and do not always necessitate the documentation of unavailability or non-existence.
  • Obtaining relevant reports of treatment that occur prior to, but approximately close to, the starting date(s) of treatment provided by the claimant, may be considered sufficient for purposes of obtaining records from the starting date(s).
References:  For more information on

III.iii.1.C.2.j.  RO Procedure for Requesting VA Form 28-1902b From VR&E 
The table below describes the steps ROs must follow to obtain VA Form 28-1902b, Counseling Record – Narrative Report, when a Veteran who is receiving VR&E benefits or has been evaluated by VR&E in the past files a claim for IU.
Important:  The RO must first check VBMS to determine if the records are already electronically available.
Step
Action
1
Refer to the BIRLS FOLDER LOCATION tab in SHARE to determine the location of the Counseling/Evaluation/Rehabilitation (CER) folder.
2
Follow the instructions in the table below.
If the CER folder is located at a …
Then …
VR&E office
send an encrypted e-mail to the VR&E office in possession of the CER folder that contains a request for a copy of VA Form 28-1902b.
storage facility
send an encrypted e-mail to the VR&E office of the RO with geographical jurisdiction over the Veteran’s current place of residence that asks the office to
  • recall the CER folder from the storage facility, and
  • provide a copy of VA Form 28-1902b.
Note:  Place a copy of the e-mail in the claims folder.
3
Once the form is received, ensure it contains the necessary information to assist in the adjudication of the IU claim.
4
Save the document as a PDF file if it has not already been converted to this format.
5
Upload the VA Form 28-1902b into the eFolder in VBMS with the following properties:
In the document field …
Enter …
SUBJECT
Vocational Rehabilitation & Employment Documents.
CATEGORY – TYPE
Education General – VA Form 28-1902b.
SOURCE
VBMS.
DATE OF RECEIPT
the date the completed form was received.
Note:  If the Board of Veterans Appeals requests the entire CER folder from the RO, follow the decision review operation center (DROC) procedures for requesting VR&E records in M21-1, Part III, Subpart iii, 1.C.2.k.
References:  For more information on

III.iii.1.C.2.k.  DROC Procedure for Obtaining VR&E Records
The table below describes the steps DROCs must follow to obtain a Veteran’s VR&E records when the Veteran is in receipt of VR&E benefits.
Important:  DROCs must first check VBMS to determine if the records are already electronically available.
Step
Action
1
Refer to the BIRLS FOLDER LOCATION tab in SHARE to determine the location of the CER folder.
2
Follow the instructions in the table below.
If the CER folder is located at a …
Then …
VR&E office
send an encrypted e-mail to the VR&E office in possession of the CER folder that contains a request for the folder.
storage facility
send an encrypted e-mail to the VR&E office of the RO with geographical jurisdiction over the Veteran’s current place of residence that asks the office to
  • recall the CER folder from the storage facility, and
  • transfer the folder to the DROC.
Note:  Place a copy of the e-mail in the claims folder.
3
Photocopy the entire CER folder once it is received.
4
Attach a cover sheet to the photocopies that identifies (for the scanning vendor) their proper indexing values.
5
Place the photocopies in their own manila folder and send the manila folder to the scanning vendor as pending work to Veterans Claims Intake Program (VCIP).
6
Return the CER folder to the VR&E office referenced in Step 2.
References:  For more information on

III.iii.1.C.2.l.  Actions Taken When an RO Is Unable to Obtain Relevant VAMC or VR&E Records
Under 38 CFR 3.159(e), ROs are required to notify the claimant when they conclude VA medical or VR&E records do not exist or further efforts to obtain them would be futile.
When the RO is unable to obtain the records, prepare a final notification letter using the Letter Creator tool, or prepare an equivalent notice using PCGL, that identifies the
  • VAMC/VR&E office(s)
  • disability(ies) and/or reason for treatment/counseling, and
  • date range of the unavailable records.
Important:
  • Claims processors may determine how to format the list of offices/disabilities/treatment/date ranges based on the individual case, as long as each set of unavailable records is clearly identified.
  • Apply the same case-by-case considerations identified in M21-1, Part III, Subpart iii, 1.C.2.i, when documenting records that are unavailable.
References:  For more information on

III.iii.1.C.2.m.  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 the Health Insurance Portability and Accountability Act (HIPAA).  When a Veteran has been treated at a Vet Center, ROs must
Important:  Do not take any additional action if the claimant does not authorize the release of the Vet Center records.
References:  For more information about

3.  Receiving Notice of a Veteran’s Admission to an MTF and Requesting Treatment Records


Introduction

This topic contains information on the action to take when the VA is notified of a Veteran’s admission to an MTF, including

Change Date

June 19, 2017

III.iii.1.C.3.a.  Processing Notification of Admission to an MTF

Follow the instructions in the table below when VA is notified of Veteran’s admission to an MTF.
Step
Action
1
Review the claims folder of the Veteran whose name is on the notification to determine whether
  • VA has granted compensation or pension to the Veteran
  • a claim for compensation or pension from the Veteran is currently pending, or
  • VA has denied the Veteran’s claim for compensation based on
    • the assignment of a non-compensable disability rating to the Veteran’s service-connected (SC) disability(ies), or
    • the Veteran’s receipt of retirement pay.
2
Do any of the conditions described in Step 1 apply?
  • If yes, proceed to the next step.
  • If no,
    • associate the correspondence in the Veteran’s claims folder that notifies VA the Veteran is hospitalized, and
    • take no further action.
3
Was the Veteran hospitalized for an SC disability?
  • If yes, take the actions described in the next step.
  • If no, take the actions described in Step 5.
4
    • filling in all of the blocks in Part I
    • placing a check mark in the boxes to the left side of the following items in Part II:
      • Hospital Report
      • 21-Day Certificate, and
      • Notice of Discharge, and
    • dating and signing the form (on behalf of the Veterans Service Center Manager (VSCM).
  • Send the first, second (21-Day Certificate-2), and third (Notice of Discharge-3) pages of VA Form 21-8359 to the appropriate MTF on a date that ensures the hospital will receive it on or after the twenty-first day of the Veteran’s hospitalization.
  • Retain the fourth page (VA Control Copy-4) of VA Form 21-8359 in the claims folder or upload it into the Veteran’s eFolder if no claims folder exists.
  • Take no further action.
5
  • Complete the first page (Request by VA-1) of VA Form 21-8359 by
    • filling in all of the blocks in Part I
    • placing a check mark in the box to the left side ofHospital Report, and
    • dating and signing the form (on the VSCM’s behalf).
  • Send the first page of VA Form 21-8359 to the appropriate MTF.
  • Destroy the second (21-Day Certificate-2), and third (Notice of Discharge-3) pages of VA Form 21-8359.
  • Retain the fourth page (VA Control Copy-4) of VA Form 21-8359 in the claims folder or upload it into the Veteran’s eFolder if no claims folder exists.
Note:  There is no mechanism in place for an MTF to notify VA if treatment for an SC disability is initiated subsequent to admission for a non-service-connected (NSC) disability. Therefore, even though hospitalization may be for an NSC disability, and entitlement to pension is not at issue, ROs must request the hospital report.

III.iii.1.C.3.b.Limitations on Requests to an MTF Pertaining to a Sensitive Diagnosis

The Department of Defense and VA have a data sharing agreement that requires MTFs to provide VA with a complete copy of the claimant’s health care treatment records upon request.  This agreement does not include medical treatment that pertains to a sensitive diagnosis.
The MTFs identified the following as sensitive diagnoses:
  • mental health
  • substance abuse
  • Human immunodeficiency virus (HIV) Acquired immune deficiency syndrome (AIDS)
  • reproductive health
  • sexually transmitted diseases
  • rape, and
  • abuse.

III.iii.1.C.3.c.  Requesting Records Pertaining to a Sensitive Diagnosis

The RO must take note of the following when requesting records pertaining 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


III.iii.1.C.3.dRequesting OPTRs From an MTF

Veterans and their beneficiaries may continue receiving outpatient treatment at an MTF after the Veteran has been discharged from military service.  The table below provides instructions for obtaining outpatient treatment records (OPTRs) from an MTF.
If outpatient treatment was at …
Then …
an Air Force, Army, Marine Corps or Navy facility
first attempt to obtain the records from JLV.  If the records cannot be located in JLV, use VA Form 21-8359 and follow the standard procedure for requesting Federal records in M21-1, Part III, Subpart iii, 1.C.1.b.
a Coast Guard facility
use VA Form 21-8359 and follow the standard procedure for requesting Federal records in M21-1, Part III, Subpart iii, 1.C.1.b.
Exception:  OPTRs pertaining to a sensitive diagnosis should be requested by utilizing VA Form 21-8359 and VA Forms 21-4142 and 21-4142a as indicated inM21-1, Part III, Subpart iii, 1.C.3.c.
References:  For more information on

4.  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

Change Date

January 29, 2016

III.iii.1.C.4.a.Accepting Medical Evidence From an MTF as an Informal Claim Prior to March 24, 2015

Prior to March 24, 2015, 38 CFR 3.157(b) (rescinded) and 38 CFR 3.701(b)required VA to
  • accept medical evidence received from an MTF as an
    • informal claim for increased benefits or informal claim to reopen a finally adjudicated claim, and/or
    • election of VA benefits, and
  • take any appropriate rating action, even if the Veteran has not submitted a formal election of VA benefits.
Reference:  For more information on finally adjudicated claims, see 38 CFR 3.160(d).

III.iii.1.C.4.b.When to Undertake Additional Development

Obtain additional information or evidence from sources other than an MTF if
  • the medical evidence obtained from an MTF is inadequate for VA rating purposes, and/or
  • additional information or evidence is required to make an equitable decision.
Note:  A VA examination may be authorized for this purpose.

III.iii.1.C.4.c.Handling a Notice of Discharge After Assigning a 100-Percent Disability Rating Under 38 CFR 4.29

Take the action described in the table below if VA
  • receives a notice of discharge after assigning a temporary, 100-percent disability rating under 38 CFR 4.29 (based on hospitalization in excess of 21 days), and
  • has not awarded the Veteran compensation because he/she is receiving military retired pay.
If the Veteran has …
Then …
a paper claims folder
reverse-file the notice of discharge in the center section of the claims folder, so that the notice remains on top of all subsequently filed material until the rating activity takes action on the hospital report.
an eFolder
consider, as an option, editing the properties of the electronic copy of the notice of discharge so as to highlight its importance for subsequent viewers. This may be accomplished by entering a phrase similar to one of the following in the SUBJECT field:
  • Received a notice of discharge after assigning a 100-percent disability rating, or
  • Veteran not awarded compensation because he/she is receiving military retired pay.
Rationale:  Taking one of the actions described in the table above will provide a reminder that, pending completion of rating action, the 100-percent rate may not be paid beyond the last day of the month in which the hospitalization or period of convalescence ended.
Reference:  For more information about editing the properties of documents inVBMS, see the VBMS  Core User Guide.
Historical_M21-1III_iii_1_SecC_1-17-17.doc May 12, 2019 2 MB
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Historical_M21-1III_iii_1_SecC_1-29-16-1.doc May 12, 2019 901 KB
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Change-June-16-2015-Transmittal-Sheet-M21-1III_iii_1_SecC_TS.doc.docx May 12, 2019 50 KB
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