Gambrell Health Services Medical Document Reviewers

Medical Case Review and Enhancement

VETERAN WORK REQUEST

Veterans Disability Work Request

Fields marked with an * are required

Requester Information

Date *

Who is requesting the veteran disability review? *

Company's Name

Point of Contact Name

First Name *

Last Name *

Phone *

Email *

Confirm Email *

Address *

City *

State *

Zip *

Type of Request

Service Connection Increase DenialDenial of Service Connection

Military Service Details

Branch of Service

ArmyAir ForceMarinesNavyCoast Guard

Duty Type

All Active dutyActive Duty plus Reserve or National Guard timeOnly reserve or National Guard time

Length of Service

MOS / Job Title

Served Overseas?

Combat Veteran?

If Yes, Combat Era

Exposed to Chemicals/Toxins?

If Yes, List Chemicals

Disability & Claims Details

Current Disability Rating

Access to va.gov?

Within 1 Year of Last Decision Letter? *

If Yes, Decision Letter Date

List Current Rated Disabilities with Percentage

List Denied Medical Conditions *

Were Denied Disabilities Present During Service?

If Yes, Did Veteran Go on Sick Call?

If Yes, List All Physical and Mental Disabilities

If No Above, When Did Disability Develop?

1 yr after discharge2–5 yrs after discharge5–10 yrs after discharge10–20 yrs after discharge

Care Sought

VA Hosp onlyPrivate doctor onlyVA Hosp and Private DoctorDid not seek care

Other Health Issues?

If Yes, List All Physical and Mental Disabilities

Records & Scheduling

Military Health Records in PDF?

After-Service Health Records in PDF?

Preferred Interview Time

Preferred Interview Day