Your primary care manager (PCM) may have typed a free-text diagnosis or sign/symptom of a disease process or injury that didn’t transfer to your master problem list as a formal diagnosis. Take the time to review each medical appointment (often referred to as an “encounter”), note, or result. Each encounter has a unique identifier (think encounter serial number) you can use for reference when you file your claim with the VA. Read the encounters to see what they say. Specifically request a digital copy of your complete medical record inclusive of all encounters held in the electronic health records (outpatient and inpatient hospital records), scanned copies of all paper records held in your legacy Medical Records Jacket, copies of scanned documents in the Healthcare Artifact and Image Management System (HAIMS) as well as all pharmacy, laboratory, and radiology/imaging studies. Recommendation 3b: visit your local Medical Treatment Facility’s (MTF) Patient Administration Department (PAD) or Records Department and file the DD Form 2870 “Authorization for Disclosure of Medical or Dental Information” (). Pay special attention to the “Master Problem List” (active and inactive) and validate that against your self-generated problem list discussed above. Recommendation 3a: Log into Tricare Online, download, and review your existing electronic medical records. While not evidence in and of itself, this list will help guide you through your own record review. Write down body systems and body parts that hurt, don’t work correctly anymore, you have prescriptions for, or simply cause concern. Recommendation 2: think about your health and make a list of issues and concerns. This will help reinvigorate your memory of where you’ve been stationed, when you were there, and help correlate dates for medical treatment. Recommendation 1: Review your service-equivalent Record Brief (Soldier/Officer/Enlisted Record Brief for Army personnel). According to the VA, not all evidence is equal, so learn more about it.Īs service members begin their journey out of the military, either by ETS or retirement, it is imperative that they spend time examining their medical records in order to ensure they help present the most-complete picture of their care to the VA. Items like military medical records, prescriptions, actual medication bottles with your name on them, DA Form 3349 Physical Profiles (Army) or DD Form 689 Individual Sick Slips, and the VA Form 21-4138 “Buddy Statement” from your Ranger Buddy who can attest to the fact he accidentally knocked you unconscious with the buttstock of a machine gun during Mountain Phase of Ranger School in 1998 are all evidence you can introduce to support your claim of service-connection. Spend time and read M21-1, Part III, Subpart iv, Chapter 5, “Evaluating Evidence and Making a Decision” to learn about defined tiers of evidence and the standards applied to each one () “Evidence is every type of proof offered to establish a fact.” Simple enough, right? No. The fact is the VA provides a number of benefits that may help cover the costs of primary and specialty care, testing, and medications for service-connected diseases or injuries resulting in financial savings for service-members in the long run. Service-connected “non-compensable” versus “compensable” and why it matters to you.Ī separated or retired service member may not see the immediate value in establishing service-connection with 0% compensable ratings. The VA can’t evaluate what it doesn’t see and while objectively comical, simply writing “20 years active duty, everything hurts”, “Marine Infantry”, or “18-hour days on the carrier flight deck” on your separation physical is likely insufficient for the VA claims examiner to establish service-connection. The VA evaluates medical records and evidence. Why should you care if the VA receives complete and accurate medical records? What I do know is how to help service members navigate the seemingly endless number of records systems between the Military Health System (MHS)/Defense Health Agency (DHA), Tricare, and civilian healthcare partners to present the most-complete record to the Department of Veterans Affairs (VA). Disclaimer: this post can’t teach you how to achieve a 100% VA disability rating because I don’t know how.
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