So, you’re starting the process of military disability separation. What’s the most important thing you should do that no one will tell you to do?
Get a COMPLETE copy of your medical records.
Now, make sure you don’t go in and just request your medical records. They won’t give them to you. Instead, request a complete COPY of them, including labs, x-rays and all consultations. All disabled veterans are entitled to receive a copy according to the Health Insurance Portability and Accountability Act.
Although you are legally entitled to a copy, the medical facility that has your records may charge you for the copy. Don’t even hesitate if they do this. Though the cost could be pretty high considering that medical records can be gigantic, it is totally worth every penny to have all your medical records at your fingertips.
Your medical records are the key to both your DoD Disability and your VA Disability. If a condition is not noted anywhere in your medical records, it makes it really hard to prove service-connection and thus qualify for disability. These records are the evidence you need to prove that you deserve every penny of your military disability pay and VA disability benefits. As long as you have access to them, you have the ability and power to properly submit a VA disability claim and appeal any incorrect ratings given by the Physical Evaluation Board or the VA.
The #1 tool for maximizing your military disability? Documentation, documentation, documentation!
You would definitely need to link it as a secondary condition in order to establish service-connection. Before a firm rating can be given, however, the VA will need to see a definite diagnosis that is causing the limited motion. Has arthritis developed in the hips? This is highly likely and often develops as a result of back problems, but will need to be clearly diagnosed. Also submitting a NEXUS letter from your physician stating that the diagnosed hip condition is caused by your spine issues will also strengthen your claim.
Hello Dr.Johnson. how are you? I want get your opinion on a claim I plan to file for limitation of movement in the hips. I have a rating for Degenerative Arthritis/Lumbar Stain which later lead to a rating for sciatica. I'm certain the issue with my hips stem from the sciatica. I'm not sure I should file the claim secondary to the Degenerative Arthritis, secondary to the Sciatica or just file a claim for hip issue as a new claim. I would greatly appreciate your feed back on how to go about filing this claim
You may need to contact the medical offices for those directly.
If you submitted them along with your claim, then they do. You should do this when you submit a new claim. If you didn't, they may still have them. You can see everything they have on the eBenefits website. If you log in, go to Manage and the Documents and Records. If you look through here, you should find everything they have. If they don't have the right documents, then you'll need to submit the correct ones with an appeal.
What if you DO have the original records? How can you ensure the VA has the same records?
Really good info, I requested my records but got no x-rays or mental health info.
Great advice. Thank you for the specificity.
I'd like to turn your last point into a full #7 instead of just an add on. I've been dealing with numerous veterans recently who have conditions noted on The VA Presumptive List (http://www.militarydisabilitymadeeasy.com/vapresumptivelist.html), but that have been denied benefits because they do not have the proper documentation. The VA Presumptive List is "presumptive" only in that is presumes conditions developed by veterans who served in certain circumstances are service-connected. This means you don't have to have the normal proof required for service-connection, but you DO have to have proof that you were in those circumstances.
Thus, documents like deployment records noting that you were in Vietnam during the required years and thus exposed to Agent Orange, or reports detailing that you were exposed to certain chemicals or radiation, etc. are essential to making sure that conditions that develop after service qualify for VA Disability.
Don't forget to specifically ask for your:
1. Deployment health (PDHA/PDRA/PDHRA/Mental Health) records, as they may or may not be readily available either with your paper medical records (if you still have paper copies) or electronic health record (EHR) such as AHLTA.
2. Your mental health records, if you have ever seen any mental health provider. These records are generally not found in your normal medical records and require special requests directly from the mental health clinics.
3. Any records from all civilian providers (they may or may not have been properly forwarded to your military doctor and incorporated into your permanent service medical records)…quite often, they are not found later in your medical records when you need them, and the civilian doctor's practice may not even exist any longer…
4. Download the actual radiology images (MRI, CT, x-ray, etc.) whenever possible, whether from military or civilian providers, in addition to the written "impressions" and "notes" that the specialist may include.
5. Dental records, often stored separately and often forgotten and easily lost over the years. If you have ever had, or ever will suffer from, anything other than normal cavities and standard tooth decay/gum issues, you will want your complete dental files, such as for TMJ, combat injuries to the mouth/jaw, etc. You may have to hunt down multiple providers, civilian/VA/military, to get as complete a dental file as possible.
6. And your "clinical medical records," which are different from your standard "service medical records" (SMR). Any inpatient medical procedures like surgeries, etc., will generate clinical medical records, stored at the Hospital that admitted you. Those clinical records may, or may not, be forwarded and completely incorporated into your SMR. Think carefully about your years of military service, and if you were ever admitted, even for one night, to a Hospital (especially in a combat zone), you should specifically hunt down the "clinical medical records" that may still be stored at that Hospital.
There are other specific types of medical-related records that may be useful to you later, such as environmental risk reports for deployed areas, etc., but obtaining the full range of medical reports MUST be your priority as noted by Dr. Johnson before you leave active duty. The longer you are separated/retired from service, the more times you move around, the more boxes you file things away (or lose), the harder it makes it to get VA disability and proper medical treatments because you can't show evidence of what was done previously…