Submission of private treatment records and private medical opinions:
Medical Opinions by your private physician:
A medical opinion from a treating physician is in many instances a critical part of a veteran’s disability compensation claim. An independent medical opinion may sway the “benefit of the doubt” in favor of a veteran’s claim, or it may actually be the missing ‘link’ or nexus in a claim. When a veteran asks his or her physician to compose a medical opinion, there are a couple of things that should be noted in it. One of most important things that should be mentioned in the medical opinion is that the medical professional has reviewed the entire medical record including the veteran’s STR’s. The medical professional should also state his or her area of expertise and additional training. For example, if the doctor is board certified in radiology, then they should state that; especially when rendering any comments regarding radiological film studies (X-rays, MRI's, CT scans etc...). Also, it is very important that the physician give their rational as to why they have come to a certain conclusion. The physician, when giving his/her rational, should also cite any relevant medical literature that may support their findings. By doing all of this, the medical opinion becomes probative. There is also certain language the physician should use when opining whether or not the disability(ies) at hand is/are related to the veteran’s service. The following phrases are from the Department of Veterans Affairs “Clinician’s Guide for Disability Examination;”
"is due to" (100% sure)
"more likely than not" (greater than 50%)
"at least as likely as not" (equal to or greater than 50%)
"not at least as likely as not" (less than 50%)
"is not due to" (0%)
The phrase “at least as likely as not” is the legal phrase that is needed for VA to award service-connection for a particular disability based on the “Benefit of the Doubt” when an independent medical opinion should be the deciding factor in the evidence of record.
Note: Contrary to popular belief, you shouldn’t send any medical articles printed from the internet. They only pertain to the general population and aren’t afforded very much weight when they are being evaluated by the decision maker. The VA needs something from a doctor that states your disability(ies) are related to your service, not something meant for the general public.
Private medical records from non VA/DoD facilities:
If you have been treated for your claimed disabilities by a private (non-VA) doctor or facility since your discharge, it is imperative that you obtain these records and submit them as evidence. By submitting these type of medical treatment records, it shows VA that you have had continuity of treatment since discharge (possibly establishing the needed "nexus" to military service) and shows VA the current symtoms of the diagnosed condition. If you're unable to obtain these types of records, for whatever reason, you may be able to have VA obtain them for you. To do so you'll need to submit VAF's 21-4142 and 21-4142a.
Note: Private treatment records from a foreign source can also be requested through the VAF's 21-4142 and 21-4142a. However, keep in mind that many foreign physicians will not understand what VA is requesting, and will simply ignore VA's request. Also keep in mind that VA's relase of records forms (the VAF's 21-4142 and 4142a) may not meet foreign privacy laws either, and may prohibit foreign doctors/facilities from releasing medical records to VA.Therefore, it's probably in your best interest to obtain any foreign medical treatment records yourself, and then submit them to VA. Also any treatment records from a foreign source do not have to be translated into English before submission. VA will have any medical evidence that is in a foreign language translated through one of their contractors for you (also at no cost to you).
The Disability Benefits Questionnaire:
In addition to any actual private treatment records you may have, you also may have your private physician fill out and sign the appropriate Disability Benefits Questionnaire (DBQ);
Please keep in mind that by submitting a DBQ for your claimed disability, this may not result in VA using it to actaully evaluate your condition. More than likely than not VA will still schedule you for the appropriate C&P anyways to verify these findings through one of their own physicians.
Submitting evidence to VA:
When submitting the above mentioned evidence, or anything else either requested from VA or you feel is relevant to your claim, VA has a new form to use as a cover sheet. You can use the below VAF 20-10208 as a cover sheet when submitting any evidence to VA.