M21-1, Part IIIFebruary 25, 2005
(1) Authorization for Release of Information. A reproduction of the "Certification and Authorization for Release of Information" section of VA Form 21-526 dated within 1 year of its being completed will generally be accepted as sufficient authority to release confidential medical information. If this authorization for release is not acceptable to the medical provider, send VA Form 21-4142, “Authorization for Release of Information,” or the release provided by the record holder, to the claimant via a BDN development or a locally generated letter.
(2) Request to Non-VA Institution for Hospital Report. Send FL 21-121 (original and one copy) with an authorization to obtain a report from a non-VA hospital.
(3) Request to Civilian Physician. Send FL 21-104 (original and one copy) with an authorization to obtain a report from an attending physician.
(4) Request to Persons Who Know Facts about Veteran's Sickness, Disease or Injury. Send FL 21-53 to each person listed on the veteran's VA Form 21-526.
(5) Action on Expiration of Control Date. Concurrently request reports from both the medical facility or physician and the claimant. If the report or statement is not received from the institution, physician or person having knowledge of the claimed condition after two attempts, forward the claims file to the rating board for rating or to direct further development.
b. Requesting Medical Information from VA Institution
(1) AMIE/CARPI Request or Use of VA Form 10-7131. If the veteran is a patient at a VA medical center or at a non-VA hospital as a VA beneficiary, and an AMIE/CAPRI request or VA Form 10-7131 admission notice has been received, indicate on the request what reports and hospital summaries are required. If requested via AMIE/CAPRI, progress notes or hospital summaries can be requested by range. If a veteran’s records are not on AMIE/CAPRI, they can be requested electronically via the VA Form 10-7131. See part IV, paragraph 18.01. Establish necessary controls to ensure the timely return of the requested reports.
(a) If an admission notice has not been received, request that information from the medical facility via AMIE/CAPRI.
(b) Similarly, if the veteran has been treated at a VA outpatient clinic and a summary of that treatment is needed, request that report via AMIE/CAPRI.
(2) Follow-Up Requests. VA must continue to send follow-up requests until we are reasonably certain that the records requested do not exist or until we determine that further efforts would be futile. This applies to all SMRs, Federal records, including VA and SSA. Change the suspense date accordingly.
c. Requesting Medical/Employment Information from Social Security Administration. If a veteran is claiming an increased evaluation for service-connected conditions or nonservice-connected pension and there is indication that he or she has claimed or is receiving disability benefits from the Social Security Administration (SSA), request copies of the medical records on which the SSA decision was based. In addition, request copies of the SSA disability decision documents. The availability of these documents will further assist with the processing of the veteran’s claim for benefits. See paragraph 9.01 for instructions on making this request.
d. Requesting Vocational Rehabilitation Records. If a veteran is claiming "individual
unemployability" and Chapter 31 training was either not found to be medically feasible or discontinued, include the vocational rehabilitation records when forwarding the claims folder to the rating activity.