Be Your Own Advocate at the Doctor

I'm Hector K, Air Force Veteran. Nobody's going to fight for your claim harder than you. A lot of that fight happens in your doctor's office.

I've heard it said that learning which conditions are often connected is a way of manipulating your records. Keep a symptom diary, the argument goes, and let the doctor lead.

The diary is good advice, and it's in here. But a symptom you never mention can't make it into your chart. So this page holds two things at once. Push hard for what's real. Never ask for what isn't.

Not sure what to bring up? Start your Claim Map, choose your conditions, and see how the VA rates each one.

Tell your doctor every symptom you actually have

Every one. The ones that seem minor. The ones that seem unrelated. The ones you've lived with so long they feel normal.

You don't have to decide what matters medically. That's your doctor's job, and what you tell them is part of what they work from.

Say what it does to your day, not only where it is. The VA rates a disability on how you function in daily life, including work.

Keep a symptom diary

Memory smooths things over. A diary doesn't. Write it down the day it happens.

• When it started, and when it ended.
• What you were doing before, and what you did after.
• How it affected work and daily life, like sleep, chores, or driving.

Bring it to every appointment. Read from it, or hand your doctor a copy.

What you write about your own symptoms is lay evidence. The VA's rule covers a person who knows the facts and describes what a layperson can observe. If you send it to the VA with your claim, the law says the VA has to consider it with all the other evidence.

Considered isn't the same as decisive. It's weighed against everything else in the file. It can describe a symptom. For most conditions, a diagnosis takes someone qualified to give one. Lay evidence covers how the Board weighs statements like this.

Ask for it to be written down

If you reported a symptom, it's fair to ask that it's in the note. Ask before you leave the room.

"I mentioned the headaches and how often they come. Can you make sure that's in today's note?" You're asking them to record what you reported. You're not asking them to agree about what caused it.

For VA care, VA's help page says you can tell your provider at your next appointment and they can update your records. You can also send your care team a secure message.

Get copies of your records and read them

VA records. Sign in to My HealtheVet on VA.gov to find, review, print, and download your VA medical records, including notes and test results. Once you sign in, find the section called "Download your medical records reports." The previous version of My HealtheVet called its download feature Blue Button.

For a complete copy, ask the Release of Information office at your VA health facility. You can ask online through a secure message, or by mail, fax, or in person with VA Form 10-5345a.

Private doctors. Under the federal health privacy rule, you have the right to see and get a copy of your records. The provider has 30 days to act. They can take one 30-day extension if they tell you why in writing. They can require your request in writing if they tell you first. Psychotherapy notes are an exception.

Then read every page. Check the dates, the medications, and that the symptoms you reported are there.

Ask for corrections to errors

You can ask to fix what's wrong or missing. A wrong date. The wrong knee. A symptom you reported that never made it in.

VA health records. Put the request in writing and send it to the Privacy Officer at the VA facility where you got care. Or use My HealtheVet secure messaging. Choose the group called My HealtheVet Record Amendment_Admin Triage Group, and type your name in the message.

Name the note title, its date, and exactly what should change. Say why it should be corrected. VA's rule says it will normally finish its review within 30 days, not counting weekends and legal public holidays.

If VA says no, its privacy notice says you'll be told in writing, with your right to appeal. You can also file a statement of disagreement that goes in your VA health record.

Private providers. The same federal rule gives you the right to ask a provider to amend your record. They can require it in writing, with a reason, if they tell you in advance. They have 60 days to act, with one 30-day extension if they explain in writing.

A provider can say no, for example if the record is accurate and complete. A denial has to be in writing and in plain language. You can then send a written statement disagreeing with it.

Ask whether it could be connected

It's fair to ask your doctor whether one condition could be connected to another. It's also fair to ask whether they'd give a medical opinion on it.

Knowing what to ask about isn't manipulating anything. Most conditions need a diagnosis from a medical professional. Most links between two conditions need a medical opinion. Start your Claim Map for secondary conditions to learn what to ask your doctor about. It never tells a doctor what to write.

Then the doctor decides what they believe, and they write it. VA's policy for its own providers calls a medical opinion the provider's "statement of findings and views". A VA provider who chooses to give one on cause has to give clear reasons and cite the evidence.

The same policy says VA providers often don't have your military medical records, and often aren't well suited to judge cause for a claim. So a VA doctor may say no. A doctor who doesn't believe it shouldn't write it.

The line you never cross

Never ask a doctor to write something they don't believe. Never report a symptom you don't have.

The VA's rules define fraud as knowingly making a false statement concerning a claim for benefits. Causing someone else to make one counts too.

Federal law says a person who does that forfeits their rights to VA benefits. The same law says that can't be imposed on someone who lived in a State when it happened. The exception is someone who stopped living in a State before the time to prosecute ran out. In this law, a State includes the territories, the District of Columbia and Puerto Rico.

Separately, it's a federal crime to knowingly and willfully make a "materially false, fictitious, or fraudulent statement" in an executive branch matter. The VA is an executive department. For most false statements, the penalty is a fine, up to five years in prison, or both.

Getting a date wrong from memory isn't knowingly false. Be honest goes through what counts, and what overstating or understating costs.

Push for what's real

Nobody's going to fight for your claim harder than you. Tell your doctor every symptom you actually have. Ask them to write it down. Get copies of your records and check them. Push for what's real. Never ask for what isn't.

I'm not your representative.