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Examination Requests  PRIVATE INFOTYPE="OTHER" Overview  PRIVATE INFOTYPE="OTHER"  In this SectionThis section contains the following topics: TopicTopic NameSee Page1General Information on Examination Requests3-A-22General Information on Social Surveys3-A-63General Medical Examinations 3-A-84Benefits Delivery at Discharge (BDD) Examinations3-A-105BDD Examinations for Pregnant Servicewomen3-A-116Prisoner of War (POW) Protocol Examinations3-A-167Former POW Social Surveys3-A-188Specialist Examinations3-A-209Medical Opinions3-A-2210Aid and Attendance (A&A) and Housebound Examinations3-A-2811Other Types of Examination Requests3-A-3012Automated Medical Information Exchange (AMIE)/Compensation and Pension Record Interchange (CAPRI) or Veterans Examination Request Information System (VERIS) Examination Requests3-A-3313VA Form 21-2507, Request for Physical Examination3-A-41 1. General Information on Examination Requests  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains general information on examination requests, including who may request an examination requesting Department of Veterans Affairs (VA) examinations when to request an examination description of terms: general medical examination, specialty examination, and specialist examination when to send the claims folders with an examination request a veterans legal rights jurisdiction for examination requests for foreign beneficiaries, and handling field investigations and examination requests for foreign beneficiaries. Change DateAugust 3, 2009 a. Who May Request an ExaminationVeterans Service Representatives (VSRs) in the Predetermination Team have primary responsibility for requesting the examination of claimants. A Rating Veterans Service Representative (RVSR) may provide guidance as necessary. RVSRs also have authority to request examinations. The Veterans Service Center Manager (VSCM) may authorize an examination in any case in which he/she believes it is warranted. b. Requesting VA Examinations Request Department of Veterans Affairs (VA) examinations from the VA Medical Center (VAMC) in whose primary service area the veteran resides VA Medical Center that is able to conduct the type of examination requested, or designated contracted provider. A listing of the counties and zip codes each VAMC serves must be maintained at each regional office (RO). Note: Because not all VA Medical Centers are able to conduct certain types of specialist examinations, it may be necessary to schedule the examination outside the primary service area in which the veteran resides. Continued on next page styleref "Map Title"1. General Information on Examination Requests, Continued c. When to Request an ExaminationReference: For more information on when to request an examination, see HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt01_ch01_secC.xml" \l "I.1.C.b"M21-1MR, Part I, 1.C.7.b. d. Description of Terms: General Medical Examination, Specialty Examination, and Specialist ExaminationThree terms are commonly used to distinguish basic categories of compensation and pension (C&P) examinations: general medical examination specialty examination, and specialist examination. General Medical Examination The main purpose of a general medical examination is to screen all body systems and either document normal findings, or identify disabilities that are found or suspected. Note: The examiner must fully evaluate any disability that is found or suspected according to the applicable worksheet for each disorder. References: For more information on general medical examinations, see HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt03_sp04_ch03_secA.xml" \l "III.iv.3.A.3"M21-1MR, Part III, Subpart iv, 3.A.3, and examination worksheets, see  HYPERLINK "http://vbaw.vba.va.gov/bl/21/Rating/Medical/exams/index.htm" Index to Disability Examination Worksheets. Specialty Examination A specialty examination focuses on the disabilities that are specifically at issue in the veterans claim. For example, if a veteran claims that service-connected arthritis in the left knee and hypertension have worsened, joint and hypertension examination worksheets should be requested. Notes: Specialty examinations generally do not address disorders that are not at issue in the claim, even if the disorders are found or suspected during the examination. Specialty examinations may be (and usually are) performed by non-specialist clinicians In unusual cases, or as requested by a Board of Veterans Appeals (BVA) remand, it may be necessary for the specialty examination to be performed by a clinician who specializes in the field of study specific to the worksheet.Continued on next page  STYLEREF "Map Title" 1. General Information on Examination Requests, Continued  STYLEREF "Block Label" d. Description of Terms: General Medical Examination, Specialty Examination, and Specialist Examination (continued)Specialist Examination A specialist examination is any examination that is conducted by a clinician who specializes in a particular field. Notes: All vision, hearing, dental, and psychiatric examinations must be conducted by a specialist. On rare occasions, it may be necessary to request a specialist examination for other types of disabilities. When requesting a mental disorders examination, specify that if possible, the veterans treating mental health professional should not perform the examination. Reference: For more information on specialist examinations, see HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt03_sp04_ch03_secA.xml" \l "III.iv.3.A.8"M21-1MR, Part III, Subpart iv, 3.A.8. e. When to Send the Claims Folder With an Examination RequestSend the claims folders to examining facilities with the examination requests only in circumstances that may require claims folder review by the examiner. In general, the claims folder should be sent for the examiners review in any case involving a request for a mental disorders examination request for a traumatic brain injury examination request for a formal medical opinion, or Board of Veterans Appeals remand. References: For more information on requests for medical opinions, see HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt03_sp04_ch03_secA.xml" \l "III.iv.3.A.9"M21-1MR, Part III, Subpart iv, 3.A.9, and handling examinations in claims for service connection for PTSD, see HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt03_sp04_ch04_secH.xml" \l "III.iv.4.D.31"M21-1MR, Part III, Subpart iv, 4.H.31. f. Veterans Legal RightsA veteran has no legal right to be accompanied by counsel during an examination, or record an examination.Continued on next page  STYLEREF "Map Title" 1. General Information on Examination Requests, Continued g. Jurisdiction for Examination Requests for Foreign BeneficiariesThe Pittsburgh Regional Office RO handles requests for field and medical examinations to be performed by the Department of State for foreign beneficiaries except for those handled by the White River Junction VAM&ROC (Canada), and Houston RO (Mexico, Central and South America, and the Caribbean). h. Handling Field Investigations and Examination Requests for Foreign BeneficiariesUse the table below for information on how to handle field investigations and medical examination requests for foreign beneficiaries. Reference: For more information on the appropriate RO to which requests must be sent, see HYPERLINK "pt03_sp04_ch03_secA" \l "III.iv.3.A.1.f"M21-1MR, Part III, Subpart iv, 3.A.1.f, and HYPERLINK "pt11_ch02_secB.xml" \l "XI.2.B.5"M21-1MR, Part XI, 2.B.5. If requesting a Then send the request to the field investigationfiduciary and field examination unit of the RO having jurisdiction over the area where development is required.medical examination on a foreign beneficiarythe Houston, White River Junction, or Pittsburgh RO by submitting the request on VA Form 21-2507, Request for Physical Examination. Reference: For more information on VA Form 21-2507, see HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt03_sp04_ch03_secA.xml" \l "III.iv.3.A.13"M21-1MR, Part III, Subpart iv, 3.A.13. 2. General Information on Social Surveys  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about social surveys, including description of a social survey when social surveys can be used to evaluate social and industrial impairment when social surveys should be used to evaluate physical or mental disability who conducts a social survey considerations when requesting a social survey, and returning social surveys for clarification. Change DateAugust 1, 2006 a. Description of a Social SurveyA social survey is an interview with the veteran to assess the impact of disability on the capacity to interact with others and function in an industrial setting. This type of information may be used in conjunction with objective clinical findings when, for example, evaluating psychiatric disabilities, examining former prisoners of war (POW), or considering individual unemployability (IU).  b. When Social Surveys Can be Used to Evaluate Social and Industrial ImpairmentA social survey is an acceptable type of evaluation of social or industrial impairment if the rating issue pertains to the evaluation of disability, and a VA examination has established the diagnosis. Reference: For information on social surveys for former POWs, see HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt03_sp04_ch03_secA.xml" \l "III.iv.3.A.7"M21-1MR, Part III, Subpart iv, 3.A.7.Continued on next page styleref "Map Title"2. General Information on Social Surveys, Continued c. When Social Surveys Should Be Used to Evaluate Physical or Mental DisabilityWhen a clinical examination alone would not provide sufficient information to assess the impact of physical and/or mental disability on the veterans capacity to interact with others and function in an industrial setting, request a social survey. A social survey may be especially useful in cases concerning veterans with psychiatric illness arrested tuberculosis loss of limbs, sight, or hearing physical disfigurement resulting in feelings of inferiority, or epilepsy. Important: Do not request a social survey in a case involving epilepsy without first obtaining the consent of the claimant. d. Who Conducts a Social SurveySocial workers are responsible for conducting comprehensive social surveys for medical and rating purposes. e. Considerations When Requesting a Social SurveyInclude ample information on the Automated Medical Information Exchange (AMIE)/Compensation and Pension Records Interchange (CAPRI) examination request worksheet or VA Form 21-2507 concerning the purpose of the examination, and evidence required for rating purposes to assist the social worker conducting the survey. f. Returning Social Surveys for ClarificationIf the rating activity determines that the social survey report is inadequate for rating purposes, it must return the report for clarification. 3. General Medical Examinations  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information on general medical examinations, including when to request a general medical examination when a general medical examination is not necessary conducting a general medical examination, and citing medical conditions to be examined. Change DateAugust 1, 2006 a. When to Request a General Medical ExaminationA general medical examination containing a full report of complaints and functional impairments is the preferred type of examination in cases concerning original compensation claims (if received within one year of discharge). It may also be appropriate to request a general medical examination to obtain evidence in claims for individual unemployability or pension. Important: A well-performed general medical examination is usually of greater value than a number of specialist examinations that are not correlated. When requesting a general medical examination to evaluate an original compensation claim received within one year of discharge, do not also generate specialty examination worksheets for each claimed disability, except when a specialist examination is required, per HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt03_sp04_ch03_secA.xml" \l "III.iv.3.A.8"M21-1MR, Part III, Subpart iv, 3.A.8. This policy applies to examinations requested from the Veterans Health Administration (VHA), as well as from private providers under VA contract.  b. When a General Medical Examination is Not NecessaryIt is not necessary to request a general medical examination if an original claim for compensation is being rated many years after separation from service.Continued on next page styleref "Map Title"3. General Medical Examinations, Continued c. Conducting a General Medical ExaminationWhen the medical examiner conducts the examination, he/she should confirm the existence of and evaluate all disabilities listed on the examination request form, and any other disabilities the veteran identifies during the examination. Reference: To review the contents of the General Medical Examinations worksheet and all other examination worksheets, see  HYPERLINK "http://vbaw.vba.va.gov/bl/21/Rating/Medical/exams/index.htm" Index to Disability Examination Worksheets.  d. Citing Medical Conditions to Be ExaminedThe examination request for a general medical examination should clearly cite the conditions or particular diagnoses that require attention. 4. Benefits Delivery at Discharge (BDD) Examinations  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about Benefits Delivery at Discharge (BDD) examinations, including who is eligible for the BDD examination, and what the BDD examination covers. Change DateAugust 1, 2006 a. Who Is Eligible for the BDD ExaminationThe Benefits Delivery at Discharge (BDD) examination program is available at specifically designated outprocessing sites to servicemembers with no more than 180 days remaining until discharge. Exception: The following are currently precluded from participation in the program: those with Gulf War undiagnosed illness or Gulf War environmental hazard issues, or complex rating issues requiring extensive development. b. What the BDD Examination CoversAt a BDD examination, the claimant is provided a general medical examination, any specialty exams deemed necessary, and full lab analyses, using VAs examination protocols. 5. BDD Examinations for Pregnant Servicewomen  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about BDD examinations for pregnant servicewomen, including general information on BDD examinations for pregnant servicewomen ancillary conditions of pregnancy tests not recommended for pregnant servicewomen how pregnancy affects participation in the BDD program options for processing BDD claims for pregnant servicewomen assisting and providing information to pregnant servicewomen providing information to the claimant, and the process when all or part of the case is rated at discharge. Change DateDecember 29, 2007 a. General Information on BDD Examinations for Pregnant ServicewomenMany pregnant servicewomen claim conditions that are either directly related to pregnancy, or acute and transitory and expected to resolve upon delivery. Some physical examinations and routine tests required to accurately rate the disabilities identified in claims are complicated and not recommended or normally performed on pregnant women since they may pose a significant health risk to the woman or baby. Important: The information in this topic also applies to pregnant veterans undergoing examination.Continued on next page styleref "Map Title"5. BDD Examinations for Pregnant Servicewomen, Continued b. Ancillary Conditions of PregnancySome ancillary conditions common to pregnancy are anemia back pain edema in the legs gestational diabetes hypertension shortness of breath, and urinary tract infections. c. Tests Not Recommended for Pregnant ServicewomenTests and procedures that are not recommended for pregnant servicewomen include x-rays pulmonary function tests (PFT), and range of motion examinations. d. How Pregnancy Affects Participation in the BDD ProgramPregnant servicewomen are allowed to participate in the BDD program; however, the claims should not be transferred to the BDD Rating Activity Site. Such cases will remain at the regional office of jurisdiction. Without diagnostic tests and procedures, the examiner may be unable to accurately assess the claimants medical condition. This would preclude completion of the examination of pregnancy-related conditions and the rating process until after delivery.  e. Options for Processing BDD Claims for Pregnant ServicewomenThere are three options for processing BDD claims for pregnant servicewomen: defer the entire examination until after delivery rate the entire claim based on existing service treatment records (STRs) and evidence, or rate any claimed conditions that may be granted based on existing STRs and evidence. Defer consideration of any additional disabilities that may not be examined until after delivery. For example, a claim for an amputated finger could be granted but the rest of the claim might be deferred until the pregnancy terminates. styleref "Map Title"5. BDD Examinations for Pregnant Servicewomen, Continued f. Assisting and Providing Information to Pregnant ServicewomenThe table below describes the process followed by the Military Services Coordinator (or VSR) at the BDD Intake Site to assist and provide the necessary information to pregnant servicewomen. StageDescription1Using the Claim Establishment (CEST) command, establishes EP 684 to control the claims development process, and enters the claim into Modern Award Processing-Development (MAP-D) tracking.2Assists pregnant servicewomen in preparing VA Form 21-526, Veterans Application for Compensation and/or Pension, documenting all personal and necessary information to facilitate future contacts. 3Provides a fact sheet to the pregnant servicewomen explaining that the disability examination is deferred because of her pregnancy the claim is not adversely affected by the deferral she must advise VA of any changes in address or telephone number the claim and STRs will be forwarded to the RO of jurisdiction the RO of jurisdiction will notify the veteran of the scheduled Compensation and Pension (C&P) examination approximately 90 days after the projected delivery date, and the claimant should contact VA via the toll free telephone number if this contact does not happen.Continued on next page  STYLEREF "Map Title" 5. BDD Examinations for Pregnant Servicewomen, Continued  STYLEREF "Block Label" f. Assisting and Providing Information to Pregnant Servicewomen (continued) StageDescription4Forwards VA Form 21-526 and STRs to the RO of jurisdiction after separation, and clears (PCLR) EP 684. Reference: For more information on the process followed by the RO of jurisdiction, see HYPERLINK "pt03_sp04_ch03_secA" \l "III.iv.3.A.5.g"M21-1MR, Part III, Subpart iv, 3.A.5.g. g. Providing Information to the ClaimantThe table below describes the process followed by the RO of jurisdiction upon receiving VA Form 21-526 and STRs from the BDD Intake Site. StageDescription1Using the CEST command, establishes EP 930 with a suspense date of 90 days after the expected delivery date, as reported by the claimant.2Schedules the C&P examination when the 90-day suspense period has matured and the claim is located via EP 930. Important: A high degree of coordination is required between the BDD Intake Site coordinator and the RO of jurisdiction to ensure the claim is complete and the EP taken accordingly.3Establishes EP 111/011, with a date of claim 90 days after the expected delivery date.Continued on next page styleref "Map Title"5. BDD Examinations for Pregnant Servicewomen, Continued h. Process When All or Part of the Case Is Rated at DischargeThe table below describes the process when all or part of the case is rated at discharge. StageDescription1The BDD Intake Site coordinator or examining physician identifies cases with significant, non-pregnancy related disability(ies), and STRs or medical board records sufficient for rating purposes.2The BDD Intake Site coordinator uses locally established BDD processing procedures, and forwards the claim to the RO of jurisdiction.3The RO of jurisdiction establishes a 111/011 EP with the date of discharge as the date of claim, and schedules a future examination to validate the rating evaluation, and address any new or deferred issues. Note: EP 111/011 remains pending if there are any deferred issues. 6. Prisoner of War (POW) Protocol Examinations  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about prisoner of war (POW) protocol examinations, including reviewing former POW claims considerations when requesting a POW protocol examination when to order initial POW protocol examinations how to order initial POW protocol examinations, and when to order reexaminations. Change DateAugust 1, 2006 a. Reviewing Former POW ClaimsReview all former POW claims, including original claims, reopened claims, and claims for an increased evaluation, to determine if the record confirms that the veteran was a POW, and veteran was examined under the POW protocol, including a social survey. b. Considerations When Requesting a POW Protocol ExaminationIf the former POW was not examined under the POW protocol, request an examination unless it would be inadvisable in light of the veterans medical condition, or is specifically declined by the veteran or the veterans representative. c. When to Order Initial POW Protocol ExaminationsOrder initial POW protocol examinations even if medical evidence to support the claim is not of record but POW status is established.Continued on next page styleref "Map Title"6. Prisoner of War (POW) Protocol Examinations, Continued d. How to Order Initial POW Protocol ExaminationsOn the examination request for an initial POW protocol examination clearly note that an examination under the POW protocol is required, and request an examination of all claimed and noted disabilities, as well as all other conditions characteristically associated with confinement as a former POW. Note: Provide the claims folder for the examiner to review on all original claims and as needed on reopened claims or claims for increased evaluations. e. When to Order ReexaminationsIf the veteran expresses dissatisfaction with either the initial examination or the rating decision based on the initial examination, order a reexamination. Reference: For more information on requesting additional information from the veteran, see HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt04_sp02_ch01_secG.xml" \l "IV.ii.1.G.24"M21-1MR, Part IV, Subpart ii, 1.G.24. 7. Former POW Social Surveys  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about former POW social surveys, including the voluntary nature of social surveys refusing social surveys handling examinations that do not include a social survey automatic scheduling of former POW social surveys, and specific scheduling of former POW social surveys. Change DateAugust 1, 2006 a. Voluntary Nature of Social SurveysSocial surveys are a voluntary examination for former POWs. b. Refusing Social SurveysNo claim should be prejudiced by the failure of a former POW to cooperate in accomplishing the survey. c. Handling Examinations That Do Not Include a Social SurveyIf a social survey was to be conducted for a former POW but was not, then return the examination as inadequate for rating purposes unless it is indicated that the former POW declined to participate in the social survey d. Automatic Scheduling of Former POW Social SurveysVHA automatically schedules a social survey after receiving an examination request for a special POW protocol examination.Continued on next page styleref "Map Title"7. Former POW Social Surveys, Continued e. Specific Scheduling of Former POW Social SurveysIn cases where a special POW examination is already of record and an additional examination for psychiatric disability is necessary, for which a social survey is advisable, specifically request a social survey in the Remarks section of the examination request. Use the table below to determine whether to specifically schedule a former POW social survey in such cases. Important: Honor all specific requests for a social survey from former POWs or their representatives. If a social survey Then was not conducted within the one year period before receipt of the claimrequest a social survey.was conducted within the one year period before receipt of the claimdo not request another social survey unless there is an indication that the social/employment situation has changed.is needed prior to other appellate procedures in cases where a notice of disagreement (NOD) has been filed the issue on appeal is either service connection or evaluation of a psychiatric disability, and upon review of the claims folder, prior to pre-certification of the appeal, it is found that a social survey was not considered in the denialrequest a social survey. 8. Specialist Examinations  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about specialist examinations, including examinations routinely performed by specialists who may request other types of specialist examinations when to request a specialist examination, and who determines the choice of examiner. Change DateAugust 1, 2006 a. Examinations Routinely Performed by SpecialistsSome examinations are routinely performed by specialists. These examinations include hearing vision dental, and psychiatric. b. Who May Request Other Types of Specialist ExaminationsIn certain circumstances, specialist examinations for other conditions can be requested by the VSR or RVSR the medical examiner, or the Board of Veterans Appeals (BVA). c. When to Request a Specialist ExaminationRequest a specialist examination only if it is considered essential for rating purposes. Example: A specialist examination may be requested if an issue is unusually complex if there are conflicting opinions or diagnoses that must be reconciled, or based on a BVA remand.Continued on next page styleref "Map Title"8. Specialist Examinations, Continued d. Who Determines the Choice of ExaminerThe choice of examiners is up to the VA medical facility conducting the examination, unless the BVA remand specifies that the examination must be conducted by a Board-certified specialist in , or specialist who is Board qualified. Note: In the absence of a BVA remand, regional offices (ROs) may not designate qualification requirements for a specialist examination. 9. Medical Opinions  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about medical opinions, including who may request a medical opinion general guidelines for requesting a medical opinion format for medical opinion requests identifying the evidence to be reviewed requesting a medical opinion instructions for providing medical opinions for general claims, and claims under 38 U.S.C. 1151 improper medical opinion requests when to obtain an independent medical opinion initiating a request for an independent medical opinion submitting a request for an independent medical opinion, and processing requests for an independent medical opinion. Change DateDecember 29, 2007 a. Who May Request a Medical OpinionA VSR assigned to the Predetermination Team may request a basic or straight-forward medical opinion if he/she has completed the Advanced Development Course. However, an RVSR must review and approve any medical opinion request initiated by a VSR. RVSRs have the sole authority to initiate complex medical opinion requests. Notes: A Veterans Service Center Manager (VSCM) may authorize a medical opinion in any case in which he/she believes it is warranted. A medical opinion request should be signed by the RVSR (or VSCM) who reviewed and approved it. Continued on next page  STYLEREF "Map Title" 9. Medical Opinions, Continued b. General Guidelines for Medical Opinion RequestsWhen requesting a medical opinion specify the issue(s) under review claimants contention(s), and opinion requested, and provide a summary of evidence available in the case. c. Identifying the Evidence to be ReviewedIdentify the evidence to be reviewed by stating on the medical opinion request form the source of the evidence (provider or facility) subject matter involved, and approximate dates covered by the evidence, and tabbing the evidence in the claims folder. Note: Advise the examiner that the review is not limited to the evidence identified on the request form or tabbed in the claims folder. d. Requesting a Medical Opinion When requesting a medical opinion clearly state the nature of the opinion required, and explain why the opinion is needed, if this would clarify the request. When requesting an opinion in compliance with BVA remand instructions, do not simply refer the examiner to the claims folder containing the remand instructions; however, the instructions may be quoted on the medical opinion request.Continued on next page  STYLEREF "Map Title" 9. Medical Opinions, Continued e. Instructions for Providing Medical Opinions General ClaimsWhen requesting a medical opinion, ask the provider to identify the specific evidence reviewed and considered in forming the opinion provide a rationale (explanation/basis) for the opinion presented, and state his/her conclusion using one of the following legally recognized phrases: [_____] is caused by or a result of [______] [_____] is most likely caused by or a result of [______] [_____] is as least as likely as not (50/50 probability) caused by or a result of [______] [_____] is less likely as not (less than 50/50 probability) caused by or a result of [______] [_____] is not caused by or a result of [______], or [_____] I cannot resolve this issue without resort to mere speculation. Note: The phrase caused by or a result of must be modified for opinion requests based on aggravation. For more information on what to include in this type of request, see HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt04_sp02_ch02_secB.xml" \l "IV.ii.2.B.6.c"M21-1MR, Part IV, Subpart ii, 2.B.6.c.  f. Instructions for Providing Medical Opinions 1151 Claims When requesting a medical opinion for a claim involving benefits under 38  HYPERLINK "http://assembler.law.cornell.edu/uscode/html/uscode38/usc_sec_38_00001151----000-.html" U.S.C. 1151, ask the provider to identify the specific evidence reviewed and considered in forming the opinion provide a rationale (explanation/basis) for the opinion presented, and state whether it is as least as likely as not that the claimed disability was caused by or became worse as a result of the VA treatment at issue the additional disability resulted from carelessness, negligence, lack of skill, or similar incidence of fault on the part of the attending VA personnel the additional disability resulted from an event that could not have reasonably been foreseen by a reasonable healthcare provider, and/or failure on the part of VA to timely diagnose and/or properly treat the claimed disease or disability allowed the disease or disability to continue to progress. Note: Do not request an examiner under VAs contract examination program to provide an examination or medical opinion on a claim involving benefits under  HYPERLINK "http://assembler.law.cornell.edu/uscode/html/uscode38/usc_sec_38_00001151----000-.html" 38 U.S.C. 1151.Continued on next page  STYLEREF "Map Title" 9. Medical Opinions, Continued g. Improper Medical Opinion RequestsDo not request a medical authority to assume any responsibility inherent to the rating activity. To prevent confusion, avoid using the word opinion when asking the examiner a question about any issue that does not require a formal medical opinion. Examples: Do not request the medical authority to determine if there is loss of use of an extremity; ask for a description of the remaining function of the extremity. Do not ask the medical authority to determine if a particular disability is service-connected (SC). Instead, identify the in-service injury, event, or illness, as well as current disability, and ask the examiner to provide an opinion as to whether or not the current disability was caused by or the result of the identified in-service injury, event, or illness. Do not ask the medical authority to provide an opinion as to whether a veteran is unemployable or entitled to individual unemployability. Instead, in the Remarks section of the examination request, ask the examiner to comment on the veterans ability to function in an occupational environment and to describe functional limitations.  h. When to Obtain an Independent Medical OpinionIf warranted by the medical complexity or the controversy of a pending claim, an independent medical opinion under  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_328.DOC" 38 CFR 3.328 may be obtained from medical experts who are not VA employees. Note: Under VAs contract examination program, the term independent medical opinion refers to an opinion request requiring a contract examiner to review medical records contained in a veterans claims folder.  i. Initiating a Request for an Independent Medical OpinionA request for an independent medical opinion under  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_328.DOC" 38 CFR 3.328, in conjunction with a pending claim, may be initiated by the RO claimant, or claimants representative.Continued on next page  STYLEREF "Map Title" 9. Medical Opinions, Continued j. Submitting a Request for an Independent Medical OpinionSubmit a request for an independent medical opinion under  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_328.DOC" 38 CFR 3.328 in writing through the Veterans Service Center Manager (VSCM) by stating, in detail, the reasons why the opinion is necessary, and the specific information or opinion required. k. Processing Requests for Independent Medical OpinionsThe table below describes how to process a request for an independent medical opinion under  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_328.DOC" 38 CFR 3.328 and identifies the responsible parties. Stage Who is ResponsibleDescription1RVSR Decision Review Officer (DRO), or service organization representative Brings the request for an independent medical opinion to the attention of the VSCM.2VSCMDecides whether the request has merit3VSCMDoes the request have merit? If yes, refers the request to C&P Service (211) for review. If no, denies the request without the need for referral to C&P Service. Important: This determination may be contested as part of an appeal on the primary issue under consideration.4Central Office (CO) C&P ServiceDecides whether the request has merit.Continued on next page  STYLEREF "Map Title" 9. Medical Opinions, Continued  STYLEREF "Block Label" k. Processing Requests for Independent Medical Opinions (continued) Stage Who is ResponsibleDescription5CO C&P ServiceDoes the request have merit? If yes notifies the claimant that the request has been approved obtains the opinion, and sends a copy of the opinion when it is available. If no, denies the request. Important: This determination may be contested as part of an appeal on the primary issue under consideration. 10. Aid and Attendance (A&A) and Housebound Examinations  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about Aid and Attendance (A&A) and Housebound examinations, including purpose of an A&A and Housebound examination when an A&A and Housebound examination may be useful requesting an A&A and Housebound examination, and prohibition against using locally devised checklists. Change DateAugust 3, 2009 a. Purpose of an A&A and Housebound ExaminationThe Aid and Attendance (A&A) and Housebound examination is designed to pinpoint findings relevant to Aid and Attendance determinations under HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_351.DOC"38 CFR 3.351 and HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_352.DOC"38 CFR 3.352, and provide a basis for determining if the Housebound benefit may be paid if need for A&A is not shown. b. When an A&A and Housebound Examination May Be UsefulIt may be useful to request an A&A and Housebound examination before a final determination is made, especially if the evidence of record demonstrates a reasonable probability of entitlement to A&A or Housebound benefits but is not sufficient to allow the benefit. Continued on next page styleref "Map Title"10. Aid and Attendance (A&A) and Housebound Examinations, Continued c. Requesting an A&A and Housebound ExaminationUse the table below for information on how to request an A&A and Housebound examination. If using Then check the the AMIE/CAPRI examination request worksheetA&A and Housebound examination field.VA Form 21-2507appropriate block in the item require medical examination of. Note: Since the Veterans Health Administration (VHA) maintains its own stock of forms, do not attach VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance. d. Prohibition Against Using Locally Devised ChecklistsDo not use locally devised checklists for completion by physicians or others. Since functional impairment is seldom total in extent, Yes or No blocks do not provide sufficient descriptive information to assess the extent of a claimants incapacitation. 11. Other Types of Examination Requests  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about other types of examination requests, including examinations of non-veteran claimants and beneficiaries hospital observation field examinations examinations of incarcerated veterans board examinations, and reexaminations by different examiners. Change DateDecember 29, 2007 a. Examinations of Non-Veteran Claimants and BeneficiariesSchedule examinations of non-veteran claimants and beneficiaries only after approval by the VSCM, or to determine whether a claimant is entitled to A&A or Housebound benefits claimant was insane at the time he/she caused the death of the veteran child claimant is helpless and/or incompetent, and/or beneficiary is competent to handle his/her funds. Reference: For more information on the facts to be considered in a wrongful and intentional death, see HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt03_sp05_ch01_secF.xml" \l "III.v.1.F.23"M21-1MR, Part III, Subpart v, 1.F.23. b. Hospital ObservationTo properly visualize and evaluate complex disability issues the rating activity may request a period of hospitalization for observation and examination.Continued on next page styleref "Map Title"11. Other Types of Examination Requests, Continued c. Field ExaminationsRequest a field examination when it is not possible, through the routine examination process, to determine the competency of the beneficiary assess employment and social adjustment, or substantiate items of evidence regarding the existence of disease or injury prior to enlistment. Reference: For more information on requests for field examinations, see  HYPERLINK "pt03_sp06_ch08.xml" \l "III.vi.8.8" M21-1MR, Part III, Subpart vi, 8.8. d. Examinations of Incarcerated VeteransBecause some State laws restrict the movement of and access to prison inmates, it may not be possible for an incarcerated veteran to be examined at a VA medical facility or for Veterans Health Administration (VHA) personnel to perform the examination at the prison. When examination of an incarcerated veteran is required, the RO and/or the local VHA Medical Examination Coordinator should confer with prison authorities to determine whether the veteran should be escorted to a VA medical facility for examination by VHA personnel, or examined at the prison by VHA personnel prison medical providers at VA expense, or fee-basis providers contracted by VHA. Note: If a problem cannot be resolved at the local level, contact the C&P Service Program Review Staff (214A) for assistance. References: For more information on VAs duty to examine incarcerated veterans, see HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm"Bolton v. Brown, 8 Vet. App. 185 (1995), and VHA Medical Examination Coordinators, see HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt03_sp04_ch03_secE.xml" \l "III.iv.3.E"M21-1MR, Part III, Subpart iv, 3.E.Continued on next page  STYLEREF "Map Title" 11. Other Types of Examination Requests, Continued e. Board ExaminationsThere should be at least two physicians, preferably three, on board examinations and at least one, preferably all, should be a recognized specialists in the particular field involved. The rating activity has the authority to request board examinations to reconcile differing diagnoses, or resolve particularly complex issues concerning grants of Special Monthly Compensation (SMC), or entitlement to specially adapted housing (SAH). f. Reexaminations by a Different ExaminerThe rating activity may request that the claimant be reexamined by another medical examiner if compelling reasons exist. To request a reexamination prepare another examination request annotate it to show that reexamination is necessary identify any specific information needed in the examination report, and include the name and the facility of the medical examiner who conducted the prior examination. Reference: For more information on preparing examination requests, see HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt03_sp04_ch03_secA.xml" \l "III.iv.3.A.13"M21-1MR, Part III, Subpart iv, 3.A.13. 12. Automated Medical Information Exchange (AMIE)/ Compensation and Pension Record Interchange (CAPRI) or Veterans Examination Request Information System (VERIS) Examination Requests  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information on the features of the AMIE/CAPRI or VERIS Compensation and Pension (C&P) program when to complete an AMIE/CAPRI C&P examination request worksheet requesting VHA examinations in the geographic jurisdiction of another RO the responsibilities of ROs in reviewing examination requests generating worksheets who uses the worksheets the information required to complete an AMIE/CAPRI C&P examination request worksheet, and handling the folder copy. Change DateDecember 29, 2007Continued on next page styleref "Map Title"12. Automated Medical Information Exchange (AMIE)/ Compensation and Pension Record Interchange (CAPRI) or Veterans Examination Request Information System (VERIS) Examination Requests, Continued a. Features of the AMIE/CAPRI or VERIS C&P ProgramThe AMIE/CAPRI or VERIS Compensation and Pension (C&P) program allows ROs to electronically transmit examination requests to medical centers, examining facilities, and private examination contractors, as appropriate ROs to add, cancel, or modify examination requests instantly ROs to use inquiry capabilities for information on the status of examination requests medical centers and examination contractors to print examination requests, and standardized worksheets after the specific examinations have been scheduled, and medical centers and examination contractors to electronically transmit transcribed results of examinations back to the RO for local printing. Notes: The VERIS application is used only at ROs that participate in the contract examination program. Use an AMIE/CAPRI or VERIS C&P examination request rather than a hardcopy VA Form 21-2507 whenever possible. Reference: For more information on VA Form 21-2507, see HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt03_sp04_ch03_secA.xml" \l "III.iv.3.A.13"M21-1MR, Part III, Subpart iv, 3.A.13.Continued on next page styleref "Map Title"12. Automated Medical Information Exchange (AMIE)/ Compensation and Pension Record Interchange (CAPRI) or Veterans Examination Request Information System (VERIS) Examination Requests, Continued b. When to Complete an AMIE/CAPRI or VERIS C&P Examination Request WorksheetUse AMIE/CAPRI or VERIS to request examinations medical opinions social surveys, and periods of hospitalization for observation and examination. Exception: Do not make requests for observation and examination or social surveys in VERIS, because VAs contract for medical services does not include these types of examinations. Reference: For more information on requesting examinations or opinions and the duty to assist, see HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt01_ch01_secC.xml" \l "I.1.C.7"M21-1MR, Part I, 1.C.7.  c. Requesting VHA Examinations in the Geographic Jurisdiction of Another ROUse the table below for requesting VHA examinations that are in the geographic jurisdiction of another RO. Note: Requests for non-VHA examinations scheduled through a designated contractor are limited to the geographic area specified by the contractual agreement. If you want to request the examination of Then the person making the examination request must a veteran living within the geographic jurisdiction of another RO, or an employee-veteran who must be examined elsewhereeither complete VA Form 21-2507, or request that an RO linked by AMIE/CAPRI to the examining facility prepare an AMIE/CAPRI examination request.a veteran residing in a foreign country other than the Philippinescomplete VA Form 21-2507. Reference: For more information on VA Form 21-2507, see HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt03_sp04_ch03_secA.xml" \l "III.iv.3.A.13"M21-1MR, Part III, Subpart iv, 3.A.13.Continued on next page styleref "Map Title"12. Automated Medical Information Exchange (AMIE)/ Compensation and Pension Record Interchange (CAPRI) or Veterans Examination Request Information System (VERIS) Examination Requests, Continued d. Responsibilities of ROs in Reviewing Examination RequestsROs must ensure that the types of examinations requested are pertinent to the veterans claim and that the request is clear and complete. e. Generating WorksheetsThe medical center clerk uses AMIE/CAPRI to generate standardized worksheets for each type of examination requested and scheduled. The private examination contractor uses VERIS for the same purposes. f. Who Uses the WorksheetsThe examiner uses the AMIE/CAPRI or VERIS standardized worksheets for conducting the examination.Continued on next page styleref "Map Title"12. Automated Medical Information Exchange (AMIE)/ Compensation and Pension Record Interchange (CAPRI) or Veterans Examination Request Information System (VERIS) Examination Requests, Continued g. Information Required to Complete an AMIE/CAPRI C&P Examination Request WorksheetThe table below shows the information required to complete entries on the AMIE/CAPRI C&P examination request worksheet. Important: Worksheets vary from one RO to another, so instructions for completion may vary. References: For more information on completing the entries on the AMIE/CAPRI C&P examination request worksheet, see the  HYPERLINK "http://vbaw.vba.va.gov/bl/21/systems/docs/amieug.pdf" AMIE Users Guide, and  HYPERLINK "http://vbaw.vba.va.gov/bl/21/systems/docs/capriug.pdf" CAPRI Users Guide. For information on completing the entries on the VERIS examination request worksheet, see the HYPERLINK "http://vbaw.vba.va.gov/bl/21/publicat/Users/Index.htm" \l "bmv"VERIS Users Guide.  ItemEntryExplanation1Veterans First Name Middle Initial, and Last NameIf the person being examined is not a veteran, enter the persons name followed by their relationship to the veteran (for example, enter Tony Smith, child, or Mary Jones, spouse.). is not a veteran, in Remarks, enter the veterans name and VA claim number. is rated incompetent, indicate this by adding incompetent after the name.2VAMC Where Examination Is RequestedThe VAMC selected should be the closest VAMC to the claimants residence unless the VAMC is unable to conduct that particular exam, or the closest VAMC able to conduct all requested examinations.3VA Claims File NumberEnter the claims folder number.Continued on next page  STYLEREF "Map Title" 12. Automated Medical Information Exchange (AMIE)/ Compensation and Pension Record Interchange (CAPRI) or Veterans Examination Request Information System (VERIS) Examination Requests, Continued  STYLEREF "Block Label" g. Information Required to Complete an AMIE/CAPRI C&P Examination Request Worksheet (continued) ItemEntryExplanation4Social Security Number (SSN)Enter the SSN if it is different than the file number. Note: Enter the SSN of the person being examined if the person is not a veteran.5Telephone Number Enter the telephone number of the person being examined.6Power of AttorneyEnter the power of attorney of the person being examined.7Date OrderedEnter the date on which the examination is requested.8ByEnter the VSRs/RVSRs name or initials and Correspondence Symbol.9Type of ExaminationBe sure to use the designated code to indicate the examination type. Applicable codes are E for Insufficient Exam I for Claim Increase ON for Original Nonservice-Connected OS for Original Service-Connected OTH for Other P for former POW R for Review Examination, and T for Terminal.Continued on next page  STYLEREF "Map Title" 12. Automated Medical Information Exchange (AMIE)/ Compensation and Pension Record Interchange (CAPRI) or Veterans Examination Request Information System (VERIS) Examination Requests, Continued  STYLEREF "Block Label" g. Information Required to Complete an AMIE/CAPRI C&P Examination Request Worksheet (continued) ItemEntryExplanation10Insufficient ExaminationIf the request is for additional information because a previous examination was inadequate, enter the following in the Remarks section: the date of the inadequate examination, and a complete explanation of the necessary corrective action.11General Medical ExaminationsIndicate any known diagnoses or complaints.12Body SystemCheck the specific examination within the affected body system to be performed. Do not check if also requesting a general medical examination.13RemarksIf known, provide the diagnosis of each disability to be examined. As appropriate, state whether service connection has been established for the disability or if it is being sought. Restrict other entries to any necessary clarifying remarks regarding the issues to be resolved, and/or the type of examination requested. Provide the name and telephone number of the requestor, in the event clarification is required. Note: Do not use manual, regulation, or code citations.14Specialist ExaminationsExplain the nature of the specialist examination requested and the reason for its request in Remarks.Continued on next page  STYLEREF "Map Title" 12. Automated Medical Information Exchange (AMIE)/ Compensation and Pension Record Interchange (CAPRI) or Veterans Examination Request Information System (VERIS) Examination Requests, Continued h. Handling the Folder CopyReverse file the claims folder copy of the AMIE/CAPRI examination request worksheet, pending receipt of the completed examination report. 13. VA Form 21-2507, Request for Physical Examination  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information on VA Form 21-2507, Request for Physical Examination, including when to use VA Form 21-2507 entries on VA Form 21-2507 of special interest forwarding examination requests to the appropriate medical center, and handling the file copy of the examination request. Change DateDecember 29, 2007 a. When to Use VA Form 21-2507When AMIE/CAPRI cannot be used because the RO is not linked electronically to the VA medical center, complete VA Form 21-2507, Request for Physical Examination, to request examinations medical opinions social surveys, and/or periods of hospitalization for observation and examination. b. Entries on VA Form 21-2507 of Special InterestComplete all appropriate entries on VA Form 21-2507. The table below describes the entries of special interest. EntryDescriptionSocial Security Number (SSN)Enter the SSN if it is different than the claims folder number.Period of ServiceEnter the earliest entitling period of service in a pension claim, or latest period of service in a compensation claim.Continued on next page  STYLEREF "Map Title" 13. VA Form 21-2507, Request for Physical Examination, Continued  STYLEREF "Block Label" b. Entries on VA Form 21-2507 of Special Interest (continued) EntryDescriptionVeterans first name middle name, and last name.If the person being examined is not a veteran draw a line through the word veteran, and substitute the appropriate designation, such as spouse for a veterans widow, or rated incompetent, indicate this by adding the word incompetent after the name.Address of Veteran or ClaimantReview correspondence from the veteran or claimant to confirm the current address. Include the current telephone number. Reference: For more information on corresponding with incompetent veterans, see  HYPERLINK "pt03_sp05_ch09_secB.xml" \l "III.v.9.B.4" M21-1MR, Part III, Subpart v, 9.B.4.Please ConductCheck block A if a general medical examination is requested (see HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt03_sp04_ch03_secA.xml" \l "III.iv.3.A.3"M21-1MR, Part III, Subpart iv, 3.A.3), and block B in all other cases, indicating the particular disabilities for examination.Service-Connected DisabilitiesList the diagnostic codes for each of the service-connected disabilities shown on the latest rating decision. Verify the correctness of the SC diagnostic code printed on VA Form 21-2507a. List the descriptive terminology for each disability as stated on the latest rating decision. Indicate by check mark those SC disabilities to be examined.Continued on next page  STYLEREF "Map Title" 13. VA Form 21-2507, Request for Physical Examination, Continued  STYLEREF "Block Label" b. Entries on VA Form 21-2507 of Special Interest (continued) EntryDescriptionOther DisabilitiesProvide an adequate description of the nature of the other disabilities to be examined.Specialist ExaminationsCheck this box to request a specialist examination. Attach a copy of any Board of Veterans Appeals (BVA) remand if the examination is required in connection with a remand. Note: Explain the nature of the examination and the reason for the request in the Remarks section.RemarksRestrict entries to clarifying remarks concerning the issue or issues to be resolved and/or the type of examination requested. Note: Do not use manual, regulation, or code citations.Claimant Represented ByIndicate by an appropriate check or annotation, the current accredited service organization of record. Note: If the person being examined is represented by a person or organization that does not have an office located at the RO check the Other block in Item 19 ,and enter the complete name and address of the person or organization.Date Signature of Authorizing Official, and Correspondence SymbolEnter the date the form is signed name of the authorizing official (must be legible), and correspondence symbol and telephone number of the authorizing official.Continued on next page styleref "Map Title"13. VA Form 21-2507, Request for Physical Examination, Continued c. Forwarding Examination Requests to the Appropriate Medical CenterForward the examination request to the clinic or medical center nearest the veterans residence that is able to conduct the type of examination requested.  d. Handling the File Copy of the Examination RequestReverse file a copy of the examination request in the claims folder pending receipt of the examination report.      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