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Department of Veterans Affairs VHA DIRECTIVE 1134(2)

Veterans Health Administration Transmittal Sheet

Washington, DC 20420 November 28, 2016

PROVISION OF MEDICAL STATEMENTS AND COMPLETION OF FORMS BY VA

HEALTH CARE PROVIDERS

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive

mandate for local policy creation, dated May 11, 2020. Amendment dated February 22,

2019 removes the mandate to develop a Medical Statements and Forms Advisory

Board. The responsible program office is also updated to VHA Office of Clinical

Operations, Office of Primary Care (10NC3) from the Office of Patient Care Services,

Primary Care Services (10P4F). The Responsibilities have been updated to replace the

Office of Patient Care Services with the VHA Office of Clinical Operations.

b. This directive:

(1) Provides updated guidance and resources for providers to assist with the

completion of medical statements and forms,

(2) Provides examples of the various types of medical statements and forms

3. RELATED ISSUES: VHA Directive 1605.01, Privacy and Release of Information,

dated August 31, 2016 and VHA Handbook 1907.06, Management of Release of

Information, dated January 18, 2013.

4. RESPONSIBLE OFFICE: The VHA Office of Clinical Operations, Office of Primary

Care (10NC3) is responsible for the contents of this directive. Questions may be

referred to 202-461-6259 or [email protected].

5. RESCISSION: VHA Directive 2008-071, dated October 29, 2008 and VHA Directive

2006-010, dated February 17, 2006, are rescinded.

AMENDED

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6. RECERTIFICATION: This VHA directive is due to be recertified on or before the

last working day of November 2021. This VHA directive will continue to serve as

national VHA policy until it is recertified or rescinded.

DISTRIBUTION: Emailed to the VHA Publications Distribution List on November 29,

2016.

PROVISION OF MEDICAL STATEMENTS AND COMPLETION OF FORMS BY VA

HEALTH CARE PROVIDERS

PROVISION OF MEDICAL STATEMENTS AND COMPLETION OF FORMS BY VA

HEALTH CARE PROVIDERS

1. PURPOSE

This Veterans Health Administration (VHA) directive establishes policy requiring

assist patients in completing Department of Veterans Affairs (VA) and non-VA medical

understand and advocate for Veterans’ concerns. Additionally, completion of medical

forms by health care providers based on an examination or knowledge of the Veteran’s

conditions, is included under Title 38 Code of Federal Regulations (CFR)

17.38(a)(1)(xv) as part of the medical benefits package (with the exception of the

completion of examination forms if a third party would customarily pay health care

practitioners for the examination, but will not pay VA). NOTE: At present, as a matter

a. Assessment of Function (or Functional Assessment). An assessment of

function provides data on how an individual relates and adjusts to their environment

when performing a specific task. Assessments of function generally will include

measures of motion, strength, pain, endurance, flare-ups, safety, and the ability to

perform and repeat meaningful tasks (e.g., assessment of daily living, reviews of

medical record, etc.). Typically, VA providers can conduct assessments of function

within the clinical environment and they can be enhanced by physical therapy,

kinesiotherapy, or occupational therapy consultation. NOTE: For example, a form

which asks a provider to estimate how long a patient can stand is considered an

assessment of function and therefore should be answered to the best of a provider’s

ability and clinical expertise based on the evaluation completed, even though the

participation in employment and compares the individual's health status and functional

status to the demands of the job and the work environment. Typically, a FCE is

conducted for the purposes of determining feasibility for employment in a specific job. A

well-designed FCE may take hours to perform and consists of a battery of standardized

assessments requiring direct observation that offers results in performance-based

measures. FCEs should only be performed by qualified rehabilitation professionals that

have appropriate training and specialized equipment to include validity and effort

measures in the evaluation. Due to the lack of specialized equipment available at most

VA medical facilities required to perform FCEs, these evaluations are not routinely

service or to a previously determined service-connected disability.

e. Personal Representative. A personal representative is a person who, under

applicable law, has authority to act on behalf of the individual. This may include power

of attorney, legal guardianship of an individual, the executor of the estate of a deceased

individual, or someone under Federal, state, local or tribal law with such authority (e.g.,

parent of a minor) (see VHA Handbook 1605.1 on the VHA Publications Web site).

f. Provider. Physicians, advanced practice registered nurses, physician

assistants, and other health care practitioners who provide primary or specialty care

services to patients in accordance with licensure, scope of practice, or functional

statement.

5. RESPONSIBILIITES

this directive.

b. Assistant Deputy Under Secretary for Health for Clinical Operations. The

Assistant Deputy Under Secretary for Health for Clinical Operations, or designee, is

responsible for:

(1) Providing national advice, direction, on medical statements and medical forms

completion; and

(2) Serving as a resource to Veterans Integrated Service Networks (VISNs), VA

medical facilities, Veterans, and others to address issues, concerns, and questions

related to this directive.

c. Veterans Integrated Service Network Director. Each VISN Director is

responsible for ensuring implementation and compliance with this directive at all VA

medical facilities in the VISN.

personal representative (see definition for personal representative) may request that VA

health care providers complete the medical forms on the patient’s behalf. Examples of

VA medical forms completed upon patient or beneficiary request include, but are not

limited to:

1. Application for clothing allowance form,

2. Aid and Attendance (A&A) pension forms,

http://www.benefits.va.gov/insurance/index.asp.

(b) Provision of Medical Statements to Support VA Benefits Claims. When honoring

requests for medical statements by Veterans for VA claims adjudication, care must be

taken to avoid conflict of interest or ambiguity.

1. Service connection and disability ratings for VA benefits are purely legal

determinations belonging exclusively to the Veterans Benefits Administration (VBA).

VHA providers often do not have access to military medical records, and may not be

familiar with all the health issues specific to military service, such as environmental

exposure. Additionally, the issues of service connection and disability ratings are

governed by statutory and regulatory provisions beyond the scope of VHA examination

a current condition in a manner helpful to inform the VBA adjudication process. VHA

providers who wish to provide medical opinions that state causality must include clear

and specific rationale citing evidence to support the conclusion reached, and should

as not”, etc.)

2. VHA providers, if requested by the Veteran, may place a descriptive statement

VA medical facility for completion.

1. Veterans may ask their primary care or specialty care provider to complete a

DBQ for conditions which are already diagnosed and documented and for which the

provider is treating the Veteran. DBQs can be completed by the treating provider during

a routine office visit when there is sufficient time and the medical information is

available. DBQs can also be completed outside of an office visit, or an appointment can

be scheduled for completion. (See VHA Directive 2013-002, Documentation of Medical

Evidence for Disability Evaluation Purposes, or subsequent policy issue, on the VHA

Publications Web site).

they can or should complete, they may seek further guidance from VBA. Additional

guidance and information on completing DBQs can be found on VHA’s Office of

Disability and Medical Assessment (DMA) website. Guidance specifically for primary

care providers is located in DMA Fact Sheet 12-002, “DBQs and Primary Care

Providers”. For a complete list of DBQs, see VA’s DBQ Switchboard Intranet page

(NOTE: These are internal VA Web sites that are not available to the public) or at VA’s

are required to complete the clinically pertinent content of non-VA forms to the best of

their ability consistent with their clinical expertise.

NOTE: For questions pertaining to a form(s) not specifically listed as example(s) below,

contact your local Medical Statements & Forms (MS&F) POC for further assistance.

c. Non-VA disability retirement forms;

school/college, therapeutic work programs, etc.);

disability claims). NOTE: Completion of attorneys’ forms or provision of statements

unrelated to the patient’s medical status or for non-medical reasons should be

evaluated on a case-by-case basis by the provider receiving the form. Examples of

such forms or statements include the provision of VA expert opinions, testimony, or

release of records strictly requested for the purposes of litigation. VA providers should

seek assistance from the local facility point of contact (POC) for consultation with their

information for completion. The provider may complete the form with or without a face-

to-face visit, as appropriate.

physical therapy, occupational therapy, blind rehabilitation, kinesiotherapy, mental

to the appropriate provider using local facility release of information processes and

4. The facility must ensure there are alternatives in place to assist Veterans with

completion of forms if the services are not available locally within VHA. Examples of

such circumstances include when completion of a form:

concealed weapons or firearms permit.

a. Develop the service at the facility-level (i.e., designate provider(s) to receive

required training or certification, at the facility expense);

b. Arrange for the service at another VA medical facility convenient to the Veteran,

in accordance with VA medical facility processes and procedures;