S06 Attachment AU - Examination Notification Letter Template (004).docx

Attachment AU - Examination Notification Letter Template Comment by Marcus, Virginia T. (The MITRE Corporation): Add directions - and picture of appt location Comment by Glenn, Mary, VBAVACO: For Long Term Contract Medical Disability Examination Contractors shall include the following standardized language when sending examination appointment notification letters to all Claimants. Below is an instruction table which identifies each topic that must be included.

person/ACE/Tele-C&P

Applicable only to in-person/Tele- C&P exams

person/ACE/Tele-C&P

Topic 1 (Applicable only to ACE exams)

If your appointment is designated as Acceptable Clinical Evidence (ACE) eligible, you are NOT required to attend an in-person examination.

The clinician will review existing records that include your electronic claims folder, existing Veterans Health Administration (VHA) and Department of Defense (DoD) treatment records, and information that may be obtained by a telephone interview with you, if needed. If additional information is required, the information will be solicited during a scheduled appointment call.

Topic 2 (Applicable only to in-person/Tele-C&P exams)

Reminders About Your Appointment:

· If you need to reschedule this examination, contact (Vendor) at (xxx) xxx-xxxx

· Do not contact the clinic where your appointment is scheduled or the VA Medical Center/clinic where you go for treatment

· If you are unable to reschedule your appointment within 5 calendar days of the original appointment date, the examination request will be returned to VBA for further review

· Bring a valid photo ID. Copies of your ID will not be made at your appointment

· Bring a list of your current medications

· For everyone’s safety, firearms and weapons are not allowed at your appointment

· Please note: Any recording, by use of any media, of the examination, to include photos, video and audio is prohibited.

Topic 3 (Applicable only to in-person)

If you are scheduled for an in-person appointment, it will take place in a (select the appropriate option from the list below)

· Hospital

· Stand-alone Clinic/doctor’s office

· Temporary/Leased Space - Non-traditional medical space (e.g. hotel facility, Veteran Claims Clinic)

· Office Building

· Home Office

· Strip Mall/Store Front-Business Suite

· Mobile Unit

Topic 4 (Applicable to all appointment letters, regardless of an in- person/ACE/Tele-C&P)

Can I Request A Specific Gender For The Examination Provider?

You can request a male or female provider in these situations:

· If you’re having a reproductive health, breast, rectal, or mental health exam, or

· If your claim is related to a mental or physical health condition resulting from Military Sexual Trauma (MST)

We understand that MST is a sensitive topic. We strive to ensure your VA disability examination is compassionate, accurate and timely. We protect your confidentiality always.

Please notify (Vendor) if you need to make a change or prefer a specific gender for your examiner.

Topic 5 (Applicable only to in-person/Tele-C&P exams) Do I Need To Attend This Appointment?

As a participant in the VA compensation and pension program, attending your examination(s) are a critical component of determining your eligibility for VA disability compensation and other benefits. If you should miss your scheduled examination(s) and need to reschedule or are unable or unwilling to attend an in-person or Tele C&P appointment(s), please notify (Vendor) at (xxx) xxx-xxxx. Your claim will not be canceled; however, your examination request will be sent back to the VA for further review.

Topic 6 (Applicable only to in-person exams) Will I Be Reimbursed For Travel To My Appointment?

You have the right to receive a mileage reimbursement allowance from your home address on file with Veterans Benefits Administration (VBA) to the disability medical examination site. If the only address on file is a Post Office (PO) Box, a residential address (place of residence or where travel started) must be provided to the contractor scheduling the appointment to calculate mileage. Travel will be reimbursed to you at a rate of 41.5 cents per mile. You will receive your payment after your appointment. Travel reimbursement will be provided per VA guidelines.

The VA permits appointments to be scheduled up to 50 miles away for medical examination(s) and up to 100 miles away for vision, audio, dental, behavioral health and TBI examination(s), unless you approve the extended mileage. You must approve any mileage in excess of the 50 or 100-mile parameters, before the exam is scheduled/completed.

Once you attend your C&P examination(s) in the U.S. or U.S. territories you will receive a reimbursement for your travel to and from your appointment(s). Please be aware that mileage for C&P examination(s) outside the U.S. and its territories is not reimbursed by the VA.

For active-duty service members, mileage for C&P examination(s) is not reimbursed by the VA.

If your address of record is a PO box, you must provide a place of residence or the location where travel started so that mileage reimbursement can be calculated.

Topic 7 (Applicable only to in-person exams) What If I Do Not Have Transportation To My Appointment?

If you do not have readily available transportation, please contact (Vendor) for additional information. Your Veterans Service Organization may also have additional resources.

Topic 8 (Applicable only to in-person/Tele-C&P exams)

Do You Have Pandemic Related Concerns About Your Appointment?

If you do not wish to attend this appointment due to concerns of increased risk of exposure, you may cancel and reschedule your appointment by contacting (Vendor) by phone at (xxx) xxx-xxxx.

· If you are showing symptoms prior to and up to the day of your appointment, please contact (Vendor) immediately to reschedule your appointment.

· If you have been in contact with someone with COVID-19, please contact (Vendor) immediately

· You may be turned away from your appointment if you are showing symptoms upon arrival

· If you are unable to reschedule your appointment within 5 calendar days of the original appointment date, the examination request will be returned to VBA for further review

· You must bring and wear a face mask. If you are unable, please reschedule when the restrictions are lifted. We are currently following federal guidelines which may differ from state and local requirements

· For everyone’s safety, please do not bring any unnecessary persons with you to the appointment, especially children. Anyone that does attend with you must bring and wear a face mask. Please note anyone in attendance with you may not be admitted into the examination room Topic 9 (Applicable only to in-person/Tele-C&P exams) Can I Attend An Examination With A Caregiver/Chaperone?

If you’d like a caregiver or family member to stay with you during the exam, you can request this when scheduling your appointment. The provider may ask caregivers and family members to stay outside of the exam room.

For sensitive physical exams, you can ask for a medical assistant or chaperone who works with the provider to stay in the room with you.

If you have children, you may want to plan for childcare during your exam. This is because you and the provider may need to discuss sensitive topics related to your claim.

Topic 10 (Applicable only to in-person/Tele-C&P exams) What If I Have Specialized Accessibility Needs?

If you have any special accessibility needs such as an inability to transfer from wheelchair to exam table on your own, or an oversized wheelchair or motorized scooter, please notify us as soon as possible to ensure that your accessibility needs are met.

Topic 11 (Applicable only to in-person/Tele-C&P exams) What Records Should I Bring or Where Should I Send Them?

If you have new non-VA medical records and/or diagnostic test results, please submit them to VA before your appointment. You may bring records to your appointment, but the provider cannot submit these records to VA for you. All new information should be uploaded online at va.gov, or submitted to your accredited representative, or mailed to VA using the address shown below:

Department of Veterans Affairs Claims Intake Center P.O. Box 4444 Janesville, WI 53547-4444 Fax: (844) 531-7818

Topic 12 (Applicable to all appointment letters, regardless of an in- person/ Tele-C&P)

How Can I Provide Feedback About My Exam?

To provide feedback regarding your medical disability examination to the VA, complete the survey card or go to https://www.research.net/r/VBAMDESURVEY.

Topic 13 (Applicable to all appointment letters, regardless of an in- person/ACE/Tele-C&P)

Where Can I Get Help?

Veteran Crisis Information: If you are in crisis or concerned about someone, you can connect with the Veterans Crisis Line to reach caring, qualified responders with the Department of Veterans Affairs. Many of them are Veterans themselves and provide free, confidential support, 24 hours a day, seven days a week, 365 days a year:

· Call the Veterans Crisis Line at 988 or (800) 273-8255 and press 1

· Online chat at www.VeteransCrisisLine.net

· Send a text message to 838255

Topic 14 (Applicable to all appointment letters, regardless of an in- person/ACE/Tele-C&P)

If you need assistance:

If you have any questions concerning your claim, you may call 1 800-827-1000. If you have questions about your claim for a mental or physical health condition related to experiences of Military Sexual Trauma (MST), you may also visit the following website to locate the Veterans Benefits Administration (VBA) Military Sexual Trauma (MST) Outreach Coordinator for your area: https://www.benefits.va.gov/benefits/mstcoordinators.asp. 2 VA provides free treatment for mental and physical health conditions related to experiences of MST. These services are available to individuals with Veteran status and most former Service members with an Other Than Honorable or uncharacterized (entry-level) discharge. To learn more, including how to access this care, go to www.mentalhealth.va.gov/mst or contact the Veterans Health Administration (VHA) MST Coordinator at a VA medical facility near you. A list of VHA MST Coordinators is available at www.mentalhealth.va.gov/msthome/vha-mst-coordinators.asp or you can contact your local VA medical facility and ask to speak to the MST Coordinator.

If you are in crisis, call the Veterans Crisis Line at 988 and then press 1, to reach caring, qualified VA responders 24 hours a day, 7 days a week. You may also text 838255 or start a confidential chat at www.veteranscrisisline.net/chat.

Topic 15 (Applicable only to in-person/Tele-C&P exams)

Can I Attend An Examination With a Service Animal?

· Yes, service animals are allowed to accompany individuals with disabilities to their examinations.

· If a service animal will be accompanying you to your appointment, please notify us as soon as possible to ensure that your accessibility needs are met.

Topic 16 (Applicable to all appointment letters, regardless of an in- person/ACE/Tele-C&P)

Veterans who Identify as Homeless or are at Imminent Risk of Homelessness

The VA’s National Call Center for Homeless Veterans hotline number is 1-877-4AID VET (1-877-424-3838).