HOW TO HANDLE THE "DOCTOR LETTER" WHEN FILING A CLAIM

When a vet ask his doctor to have his conditions diagnosed with put in their medical records and the doctor does not, or belittles the severity, refuses to make a link between the service and the current medical condition, or tells the veteran one thing then puts something else in the records (this is the most common problem), take someone to write down everything the doctor says then ask him to sign it. You can also prepare a letter like below and ask the doctor to sign it.

There is the constant rumor in VA circles that primary care physicians aren’t
allowed to assess or report their opinions about your disability.

Like so many other of the “rules” and “law” we get quoted to us, that one
isn’t correct. VA employees often discourage their physicians from becoming
involved in writing lengthy letters because it’ll put them behind schedule
and may cause extra work for the employees that have to support the
providers. VA docs don’t often have access to transcriptions and typing
pools and dictation stations so if they’re to provide you a letter,

how does it get done with a minimum of fuss?

That’s pretty easy…you do the letter yourself. You then ask your provider to
review it with you and sign it. We’ve covered some of this before and as I’d
noted then, most providers are happy to sign a well written, truthful and to
the point document.

Before you yell at me…this is a perfectly legitimate process. You aren’t
putting words in the doctor’s mouth and you aren’t asking your provider to
make any statement that isn’t true and verifiable. All you’re doing is
greasing the skids so that the process of getting good information about
your medical condition to the VBA is a smoother one. In fact, you’re making
a contribution of your labor to VA and saving them time and money.

This is legal, it assists you in gaining benefits, saves the VA some tight
budget dollars and is non-fattening, a winner all around.

Having said all that, don’t tell any of the staff you’re asking your doctor
to sign a letter for you. They’re likely to try to convince you he can’t do
that or she doesn’t have the time or that it’s against the law.

Wait until you’re comfortably in a private setting and ask if you may
address the issue of some forms with him. Let her know how important this is
to you and promise to make it quick.

Here are a few of the basics to get a good document written. I’ll assume
that you’ll produce a neatly typed, spell checked document that looks as
professional as you can get it. Don’t play with fancy fonts or scripts, no
attempts at letterhead designs are necessary or desirable. Brevity is best,
keep it all short and sweet and direct. Stick with basic business style
formats and it’ll be received a lot better.

You’ll be writing this from the perspective of the provider. This can get a
bit tricky so pay close attention to your work and have a friend or family
member proof it for you.

The opening may be addressed as follows and does not have to be addressed to
VA. The first paragraph or two are routine and serve to establish
credentials and knowledge. The body contains some details and the end brings
us to the provider’s conclusions.

Date : 01/01/ 2006

Subject: Medical history of

John or Jane Doe

The Doe’s Address

Reference: C-File # and/or SSN

To who it may concern:

I am the primary care provider for John Doe. In my capacity as a primary
care provider at the Eastern Regional Central Western Veterans
Administration Clinic, I have cared for Mr. Doe since 01/01/2001.

While I’ve provided care for Mr. Doe, I’ve become familiar with his medical
history, past and present ailments and I’ve reviewed pertinent parts of his
military record that document his injury, disease and clinical conditions
related to the events that occurred.

I am aware that Mr. Doe was (injured, got ill, sustained harm) during his
active duty military service on or about 01/01/1976. The results of this
(injury, illness) have been long lasting and his condition has worsened as
he has gotten older.

For the past (state a period of time your condition has worsened) Mr. Doe
has suffered (increasing pain, inability to walk, shortness of breath, name
your symptoms here) and continues to undergo treatment by me and specialty
clinic (ortho, neuro, podiatry) physicians.

Mr. Doe’s treatments and medications are as follows;

Name a treatment (Example; Physical Therapy, how often, etc.)

Name a medication (Side Effect)

Repeat until you have it all listed.

I have observed that Mr. Doe has challenges with functions of daily living
and requires assistance in grooming and hygiene such as combing his hair or
bathing. Mr. Doe is not able to prepare meals for himself although he is
able to feed himself. He is unable to participate in housecleaning
activities and requires someone to do his laundry and dishes and generally
keep his environment clean for him. Mr. Doe is sometimes able to complete
bladder and bowel activity unaided but there has been an increasing
frequency of soiling accidents.

Mr. Doe has chronic pain due to his injury and requires (name medicine)
which often has a side effect of dizziness and nausea. His pain level is
often quite high with reports of 8 on a scale of ten.

Mr. Doe has hypertension that requires (name medicine) and this medicine can
have the side effects of a slower heart rate or dizziness as well as
frequent and urgent urination. Mr. Doe must always be near a restroom in
case of an urgent need to use that facility.

Mr. Doe gets very fatigued because of the pain that is caused by any
strenuous activity. Mr. Doe is unable to lift more than 5 pounds
consistently and can not push or pull more than 10 pounds consistently.

Standing for long periods of time (more than 10 minutes) will make him
become weak and dizzy. He is unable to reach overhead or to bend at the
waist to retrieve fallen items. Either action will upset his equilibrium and
may cause him to become dizzy and fall.

I have examined Mr. Doe’s chart and medical record and it is my opinion that
there is a medical nexus between Mr. Doe’s active duty service connected
injuries and his disability of today. It is also my opinion that Mr. Doe is
totally and permanently disabled, can not hold gainful employment and is not
a likely candidate to be rehabilitated.

Signature Block Date
Address of Clinic/Hospital

You’ll obviously have to modify the above to fit your personal situation but
the outline as you see it is effective. Get it signed, make some copies and
submit it as evidence to support your claim. The points you should remember
are that you don’t want to exaggerate your condition…the doctor who affixes
a signature to this will want it to be point-on to your condition and isn’t
likely to sign it if you’ve over-inflated your problems. At the same time,
don’t leave out the smallest detail. Your pain is very important and you
should describe it in very certain terms. Is it aching, stabbing, deep, all
the time or burning? Does pain cause you to lose sleep? Are you angry or
losing your temper because of the level of pain? How does pain affect your
family or your ability to get along at work?

Not all providers will welcome this. A lot depends on your relationship with
your provider. They’re human too, if you’ve been a “good patient”; on time
for appointments, compliant with medications and treatments and friendly
with the doc and the staff…you’re much more likely to succeed here than if
you’re one of the complainers and fault finders.

Maybe it’s time to think about it before you need that letter…where do you
fall in those groups? If you can’t honestly say “good patient”, you may be
working against yourself.