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Appendix A: VA Forms and Documentation

Essential VA Forms for Secondary Claims

Successfully navigating the VA claims process requires using the correct forms at the right time. This appendix provides a comprehensive guide to the forms most relevant to secondary service connection claims, with detailed instructions for completing each one effectively.

Primary Claim Forms

Form Number	Form Name	Purpose	When to Use
VA Form 21-526EZ	Application for Disability Compensation and Related Compensation Benefits	Primary form for filing new disability claims, including secondary conditions	Filing initial claims for service connection Filing for secondary service connection Requesting increased ratings Adding new conditions to existing claims
VA Form 21-0966	Intent to File a Claim	Establishes an effective date while you gather evidence	When you need more time to gather evidence When you’re not ready to file a complete claim To preserve an earlier effective date Before working with a VSO on claim development
VA Form 21-4138	Statement in Support of Claim	Provides additional information or explanations	Explaining the connection between conditions Providing personal observations Clarifying timeline or progression Supplementing medical evidence
VA Form 21-4142	Authorization to Disclose Information to VA	Authorizes VA to obtain private medical records	When relevant records are held by private providers When you want VA to request records directly For each non-VA provider with relevant records When records are too voluminous to submit yourself
VA Form 21-4142a	General Release for Medical Provider Information	Continuation sheet for listing multiple providers	When you have records from multiple providers As an attachment to VA Form 21-4142 When provider information won’t fit on 21-4142 For comprehensive medical record requests

Appeal Forms

Form Number	Form Name	Purpose	When to Use
VA Form 20-0995	Decision Review Request: Supplemental Claim	Requests review with new and relevant evidence	When you have new evidence addressing denial reason Within one year of decision to preserve effective date After Higher-Level Review or Board decision When you need to submit additional evidence
VA Form 20-0996	Decision Review Request: Higher-Level Review	Requests senior review of existing evidence	When you believe VA made an error in evaluation When no new evidence is needed Within one year of decision to preserve effective date When you want to request an informal conference
VA Form 10182	Decision Review Request: Board Appeal	Appeals to Board of Veterans’ Appeals	After exhausting lower appeal options For complex legal or medical issues Within one year of decision to preserve effective date When you want a Veterans Law Judge to review your case
VA Form 21-22	Appointment of Veterans Service Organization as Claimant’s Representative	Designates a VSO to represent you	When appointing a VSO to help with claims When changing from one VSO to another Before working with a VSO on appeals When you want a VSO to access your records
VA Form 21-22a	Appointment of Individual as Claimant’s Representative	Designates an attorney or claims agent	When appointing an attorney to represent you When appointing an accredited claims agent When changing representatives When you need specialized representation

Completing VA Form 21-526EZ for Secondary Claims

VA Form 21-526EZ is the primary form for filing disability claims, including secondary service connection claims. This section provides detailed guidance for completing this form specifically for secondary conditions.

Key Sections for Secondary Claims

Pay particular attention to these sections when filing for secondary service connection:

Section I: Veteran’s Information

Complete all personal information accurately. Ensure your contact information is current so VA can reach you regarding your claim.

Section II: Disability Benefits Questionnaire

Check “New Claim” if this is your first claim for this secondary condition. Check “Supplemental Claim” if you’re refiling after a denial.

Section IX: Disabilities Claimed

This is the most critical section for secondary claims. For each secondary condition:

List the specific diagnosis of your secondary condition
Clearly indicate it is a secondary condition by writing “SECONDARY TO [primary condition]” after the diagnosis
Example: “Hypertension secondary to service-connected diabetes mellitus”
If claiming both direct and secondary theories, note both
Example: “Depression secondary to service-connected chronic pain; alternatively, direct service connection due to combat experiences”

Section X: Evidence to Support Your Claim

Identify all evidence you’re submitting or want VA to obtain:

List all private medical records you’re submitting
Identify VA medical facilities where you’ve been treated
Note any private providers from whom VA should request records (complete VA Form 21-4142 for each)
List any medical opinions specifically addressing the secondary connection
Identify any lay statements or other supporting evidence

Section XI: Claim Certification and Signature

Sign and date the form. An unsigned form will delay processing.

Effective Language for Secondary Claims

How you describe your condition in Section IX can significantly impact how VA processes your claim. Consider these examples:

Less effective: “Back pain”
More effective: “Lumbar degenerative disc disease with radiculopathy secondary to service-connected right knee condition”
Less effective: “Depression”
More effective: “Major depressive disorder secondary to service-connected chronic pain from multiple service-connected orthopedic conditions”
Less effective: “Sleep problems”
More effective: “Obstructive sleep apnea secondary to service-connected PTSD and weight gain from PTSD medications”

Be specific about both the diagnosis and the service-connected condition causing or aggravating it.

Supplemental Information

Consider attaching these additional documents to strengthen your secondary claim:

Cover letter explaining the secondary connection and summarizing evidence
VA Form 21-4138 (Statement in Support of Claim) detailing:
- How your service-connected condition causes or aggravates the secondary condition
- Timeline showing when the secondary condition developed or worsened
- How the conditions interact in your daily life
- Any observations from medical providers about the relationship
Medical opinion letter from your provider specifically addressing:
- The diagnosis of the secondary condition
- The medical relationship to your service-connected condition
- Whether it’s caused by or aggravated by the primary condition
- The medical rationale for the connection
Relevant medical records highlighted to show:
- Diagnosis of the secondary condition
- Treatment notes mentioning the relationship between conditions
- Test results supporting the connection
- Medication records showing treatments for both conditions
Medical literature supporting the connection between your conditions

Sample Completed Form Excerpt

Section IX: Disabilities Claimed

1. Peripheral neuropathy, bilateral lower extremities, secondary to service-connected diabetes mellitus type 2

2. Erectile dysfunction secondary to service-connected diabetes mellitus type 2 and medications for service-connected PTSD

3. Depression secondary to chronic pain from service-connected lumbar spine condition

Section X: Evidence to Support Your Claim

VA Medical Evidence:

VA Medical Center, Boston, MA – Treatment records from January 2018 to present
VA Medical Center, Providence, RI – Neurology consultation on March 15, 2022

Private Medical Evidence (attached):

Dr. James Smith, Neurologist – Medical opinion letter dated April 10, 2023, addressing relationship between diabetes and peripheral neuropathy
Dr. Sarah Johnson, Psychiatrist – Treatment records from June 2021 to present and medical opinion letter dated March 28, 2023, addressing relationship between chronic pain and depression
Boston Medical Center – EMG/NCS test results from February 12, 2023

Additional Evidence (attached):

Personal statement explaining progression of symptoms
Statement from spouse regarding observed limitations
Medical journal article on diabetes and peripheral neuropathy
VA Form 21-4142 for Dr. Robert Williams, who has additional relevant records

VA Form 20-0995: Supplemental Claims

Use this form when you have new and relevant evidence to address the reason your claim was denied.

Key Sections

Section III: Issues for Supplemental Claim

Clearly identify the specific issue(s) you’re requesting VA to review:

List the exact condition as it appeared in your denial letter
Include the date of the decision you’re appealing
Specify that it’s a secondary service connection claim
Example: “Denial of service connection for depression as secondary to service-connected lumbar spine condition, decision dated March 15, 2023”

Section IX: New and Relevant Evidence

Identify all new evidence you’re submitting or want VA to obtain:

List each piece of new evidence specifically
Explain why each item is relevant to the reason for denial
If VA needs to obtain records, complete VA Form 21-4142
If evidence isn’t yet available, note what’s being obtained and when it’s expected

What Qualifies as “New and Relevant”

For Supplemental Claims, evidence must be both:

New: Not previously submitted to or considered by VA
Relevant: Relates to the reason your claim was denied

Examples of new and relevant evidence for secondary claims:

Medical opinion specifically addressing the nexus requirement that was cited as missing in your denial
Recent medical literature supporting the connection between your conditions
New diagnostic test results confirming a relationship
Statement from a specialist who recently began treating you
Medical records documenting worsening of the secondary condition in relation to the primary condition

Simply resubmitting the same evidence or disagreeing with the decision without new evidence is not sufficient for a Supplemental Claim.

VA Form 20-0996: Higher-Level Review

Use this form when you believe VA made an error in evaluating the evidence already in your file (no new evidence allowed).

Key Sections

Section III: Issues for Higher-Level Review

Clearly identify the specific condition and decision you’re appealing:

List the exact condition as it appeared in your denial letter
Include the date of the decision you’re appealing
Specify that it’s a secondary service connection claim
Example: “Denial of service connection for lumbar radiculopathy as secondary to service-connected knee condition, decision dated April 10, 2023”

Section IV: Informal Conference

Consider requesting an informal conference to discuss the errors you believe occurred:

Check “Yes” if you want to speak with the reviewer
Provide a phone number where you can be reached
Prepare talking points focusing on specific errors
Be available during the time periods you select

Section V: Errors

Clearly identify the specific errors you believe VA made:

Be specific about what evidence was misinterpreted or overlooked
Cite relevant regulations or procedures that were misapplied
Identify any duty to assist violations
Explain how the error affected the outcome

Sample Error Description

“The rating decision dated April 10, 2023, denying service connection for lumbar radiculopathy as secondary to my service-connected knee condition contains the following errors:

The decision states there was ‘no medical evidence linking the radiculopathy to the knee condition,’ but my file contains a letter from Dr. Johnson dated February 15, 2023, specifically stating that my altered gait from my knee condition has caused increased stress on my lumbar spine resulting in radiculopathy. This evidence appears to have been overlooked.
The C&P examiner failed to address aggravation as a basis for secondary service connection, focusing only on direct causation, which violates the duty to consider all theories of entitlement under 38 C.F.R. § 3.310(b).
The decision applied an incorrect legal standard by stating I needed to prove my knee condition was ‘the primary cause’ of my radiculopathy, rather than applying the correct ‘at least as likely as not’ standard required by 38 C.F.R. § 3.102.

I request a Higher-Level Review to correct these errors and properly evaluate the evidence already in my file.”

VA Form 10182: Board Appeal

Use this form to appeal directly to the Board of Veterans’ Appeals after receiving a decision on a Supplemental Claim or Higher-Level Review.

Key Sections

Section III: Board Review Option

Select one of three review options:

Direct Review: No new evidence, no hearing (fastest option)
Evidence Submission: Submit new evidence within 90 days, no hearing
Hearing: Request a hearing and submit new evidence (longest wait time)

Your selection determines whether you can submit new evidence and/or have a hearing.

Section IV: Issues on Appeal

Clearly identify the specific issues you’re appealing to the Board:

List each denied condition separately
Include the date of the decision you’re appealing
Specify that it’s a secondary service connection claim
Example: “Denial of service connection for depression as secondary to service-connected chronic pain, Supplemental Claim decision dated May 20, 2023”

Section V: Certification and Signature

Sign and date the form. An unsigned form will delay processing.

Selecting the Right Board Docket

Your choice of Board review option significantly impacts your appeal:

Review Option	When to Choose	Considerations
Direct Review	When you believe the evidence already in your file supports your claim When you want the fastest decision When you have no new evidence to submit	Fastest processing time (goal: 365 days) No new evidence allowed No hearing with a judge Decision based solely on evidence already in file
Evidence Submission	When you have new evidence not previously considered When you don’t need a hearing When you can submit all evidence within 90 days	Moderate processing time Must submit all evidence within 90 days of filing No hearing with a judge Good balance between speed and ability to submit new evidence
Hearing	When you want to testify before a judge When your case involves complex issues best explained verbally When you have new evidence and want to explain its significance	Longest processing time Can submit evidence at the hearing and within 90 days after Includes hearing with a Veterans Law Judge Allows you to present your case directly to the decision-maker

For secondary service connection appeals, the Evidence Submission option is often a good choice if you have new medical opinions or literature supporting the connection between your conditions.

Additional Documentation Strategies

Beyond the required forms, certain additional documentation can significantly strengthen your secondary service connection claims. This section provides guidance on preparing these supplemental documents.

Effective Cover Letters

A well-crafted cover letter can guide VA adjudicators through your evidence and clarify your claim:

Components of an effective cover letter:
- Clear identification of the claim type (secondary service connection)
- List of all conditions being claimed
- Summary of service-connected conditions that are causing or aggravating the secondary conditions
- Brief explanation of the medical relationship
- Roadmap of the evidence being submitted
- Reference to relevant regulations (38 C.F.R. § 3.310)
Format recommendations:
- Keep to 1-2 pages maximum
- Use clear headings and bullet points
- Include your VA file number and claim number
- Reference attached evidence by name
- Sign and date the letter

Sample Cover Letter

John Veteran
123 Main Street
Anytown, USA 12345
VA File #: 123456789

May 15, 2023

Department of Veterans Affairs
Regional Office
Anytown, USA 12345

RE: Secondary Service Connection Claim for Peripheral Neuropathy and Depression

To Whom It May Concern:

I am submitting a claim for secondary service connection for the following conditions:

Peripheral neuropathy of bilateral lower extremities as secondary to my service-connected diabetes mellitus (currently rated at 40%)
Major depressive disorder as secondary to chronic pain from multiple service-connected orthopedic conditions (lumbar spine rated at 40%, right knee rated at 30%, and left shoulder rated at 20%)

These secondary conditions have developed as a result of my service-connected disabilities as explained in the attached medical evidence. I am submitting this claim in accordance with 38 C.F.R. § 3.310, which provides for service connection for disabilities that are proximately due to or aggravated by service-connected conditions.

Evidence Submitted:

VA Form 21-526EZ, Application for Disability Compensation
Medical opinion from Dr. James Smith, Neurologist, dated April 10, 2023, explaining the causal relationship between my diabetes and peripheral neuropathy
EMG/NCS test results from Boston Medical Center dated February 12, 2023, confirming diabetic neuropathy
Medical opinion from Dr. Sarah Johnson, Psychiatrist, dated March 28, 2023, explaining how chronic pain from my service-connected orthopedic conditions has caused my depression
VA Form 21-4138, Personal Statement, detailing the progression of my symptoms and their impact on daily functioning
Statement from my spouse describing observed changes in my mobility and mood
Medical literature on the relationship between diabetes and peripheral neuropathy
VA Form 21-4142 for Dr. Robert Williams, who has additional records relevant to my claim

The enclosed evidence clearly establishes that my claimed conditions are at least as likely as not caused by my service-connected disabilities. I respectfully request that VA grant secondary service connection for these conditions.

Thank you for your consideration of my claim.

Sincerely,

John Veteran

Personal Statements (VA Form 21-4138)

A detailed personal statement can provide crucial context for your secondary claim:

Elements to include:
- Chronological timeline showing when your primary condition began and when you first noticed symptoms of the secondary condition
- Specific examples of how your primary condition affects or causes your secondary condition
- Description of how both conditions impact your daily functioning
- Medications for your primary condition and any side effects related to your secondary condition
- Statements from medical providers about the relationship between your conditions
- Failed treatments or management strategies
Format recommendations:
- Use clear, chronological organization
- Be specific about dates, symptoms, and impacts
- Focus on the relationship between conditions
- Avoid medical terminology unless you’re certain of its meaning
- Be honest about the severity and frequency of symptoms

Key Concept

The Importance of Proper Documentation

Secondary service connection claims often succeed or fail based on the quality and completeness of your documentation. The forms and supporting materials you submit create the foundation upon which VA will evaluate your claim.

Remember that VA adjudicators process hundreds of claims and may spend limited time on each one. Clear, organized, and complete documentation makes it easier for them to understand and approve your claim.

Quick Tips

Always keep copies of everything you submit to VA
Submit forms via certified mail or with delivery confirmation
Use VA’s eBenefits portal to track claim status
Consider working with a VSO to review your forms before submission
File an Intent to File (VA Form 21-0966) as soon as you consider claiming a condition

← Previous – Chapter 22: Presumptive Conditions and Secondary Claims
Next – Appendix B: Medical Evidence Development →