February 25, 2005M21-1, Part III
CHAPTER 5. REQUESTS FOR MEDICAL/EMPLOYABILITY EVIDENCE
SUBCHAPTER I. GENERAL COMPENSATION CLAIMS
Note: VA has a duty to assist the claimant in obtaining evidence to substantiate a claim. Procedures described in paragraph 1.02 are to be followed when requesting all types of evidence.
Abbreviations, acronyms, etc., are used throughout the chapter. A complete list is included as Appendix A.
5.01 SERVICE MEDICAL RECORDS
We must get all available service medical records. Ascertain the alleged disabilities and any dental conditions from the claim, including the dates and places of examination or treatment. Carefully review any available service medical/dental records in the claims folder to find records supporting the claimed disabilities. Submit requests for service dental and medical records on the same Request for Information. If possible, make the request for records using the Personnel Information and Exchange System (PIES). Refer the service medical records to the rating activity for review.
5.02 CLAIMS BASED ON POSITIVE TUBERCULIN REACTION
a. Positive Tuberculin Reaction is Sole Condition Claimed. If VA Form 21-526 is received claiming only a positive tuberculin reaction, refer the claim to the rating activity for a determination as to whether or not a disability is present (pt. IV, par. 23.05).
b. Other Disabilities Claimed. If a VA Form 21-526 indicates that a positive tuberculin reaction is claimed together with other disabilities, complete any appropriate development required for the other disabilities. Refer the file to the rating activity for rating of all claimed disabilities.
c. Follow-Up Report. As provided in part IV, paragraph 23.05, a VA outpatient clinic or medical center will furnish a report of the follow-up examination made on expiration of the 12-month period of chemotherapy to discharged personnel who have had a tuberculin test conversion from negative to positive during service. If this report or any other evidence indicates the presence of tuberculous disease, take appropriate rating action. Give due regard to establishment of service connection by way of presumption under 38 CFR 3.307 (par. 5.05d).
5.03 REQUESTS FOR MEDICAL/EMPLOYMENT EVIDENCE FROM NONSERVICE SOURCES
Request any treatment records that the claimant has identified and that are relevant to the disposition of the claim. Advise the non-VA institution, physician, etc., that VA cannot pay for the information requested. Establish a 60-day control for receipt of the records. If no response is received, follow the duty to assist procedures in par. 1.02.
a. Requesting Medical Information from Non-VA Sources. Treatment reports from non-VA sources will not ordinarily be furnished without a current authorization by the claimant or, if the patient is incompetent, fiduciary or next of kin. Send the VA Form 21-4142 to the claimant (or fiduciary or next of kin) if not already of record. When evidence is requested, simultaneously notify the claimant that the request is made, but that he or she is ultimately responsible for seeing that the records are provided. The records may be requested from the claimant via the 203 screen (HOSPITAL/DOCTOR REPORT).