(Note: I published an updated version of this article on my other website, PTSDexams.net: How to Correct VA Medical Records.)
This article explains how veterans can correct errors in their Department of Veterans Affairs medical record.
If you have never downloaded your VA healthcare records using MyHealtheVet, then JUMP Down the page to MyHealtheVet.
Federal law specifically guarantees veterans the right to request a correction to their Department of Veterans Affairs medical record.1
The Veterans Health Administration (VHA) spells out specific procedures for veterans to request a correction, called an "amendment" by VA.
The procedures also assign responsibility for such making such corrections to specific VHA personnel.2,3
1. Type a letter "... stating explicitly what information is in contention and why, i.e., inaccurate or erroneous, irrelevant, untimely, or incomplete."4
In plain language, tell VA what they got wrong, and what the record should say.
2. Include with your letter a copy of the doctor's note (or whatever the record is), and use a yellow highlighter to identify the sentence, paragraph, or other aspect of the record that is not correct.
3. Include in your letter:
4. If for some reason you cannot include a copy of the medical record, be as specific as possible describing the specific medical record with the mistake, such as the ...
5. Sign your letter in ink.
6. Make three copies of your letter, in case you later need to send a copy to your Congressional Representative, Veterans Service Officer, or an attorney.
Hopefully, that will not be necessary, but it's better to "plan for the worst, and hope for the best."
7. a) Address your letter to the Privacy Officer at your VAMC or VAHCS (VA Health Care System) main facility.
You can try to find the Privacy Officer's name and an exact mailing address for him or her, but that often turns out to be an exercise in futility.6
Therefore, I suggest simply addressing your letter to "Privacy Officer" at your medical center's main mailing address. (You can usually find that on the medical center's website or by searching Google, Bing, or DuckDuckGo for "VA medical center".)
b) Send a copy of your signed letter to the Chief, Health Information Management Services at the same address.
c) It is often a pain to use a computer and a printer to type (print) an address on an envelope. It was easier with typewriters back in the day!
But if you can print the address on the envelope, it might arrive at your VAMC a little faster, with a bit less chance of getting lost on the way.
Use the U.S. Postal Service Zip Code Lookup to determine the exact address format for your VAMC. Since machines will read your envelope, it's helps to type the address in a machine-friendly way. ;^]
For example, here is how an address for VA Community-Based Outpatient Clinic is typed on the VA website:
Hilo Community Based Outpatient Clinic
1285 Waianuenue Avenue, Suite 211
Hilo, HI 96720
Plugging that in to the USPS Zip Code Lookup you get:
HILO COMMUNITY BASED OUTPATIENT CLINIC
1285 WAIANUENUE AVE STE 211
HILO HI 96720-1209
d) Go to your local U.S. Post Office and mail your letter via Certified Mail, Return Receipt Requested. If you are not sure which forms to use to request those two services, go to the Post Office at a time when it is less busy and ask the clerk for help. Let them know you are a veteran as most folks like to help veterans, and many U.S. Postal Service employees are veterans too. You can also review the Postal Service website for more information. https://www.usps.com/
Send via the U.S. Postal Service, either First-Class Mail® or Priority Mail®. To either of those options, add Certified Mail® and Return Receipt.
Total cost for business-size envelope, mailed First Class, Certified, Return Receipt is about $6.70.
Total cost for Priority Mail, Flat Rate envelope/mailer, Certified Mail, Return Receipt is about $12.90.
Certified Mail® - Prove you sent it. See when it was delivered or that a delivery attempt was made, and get the signature of the person who accepts the mailing when combined with Return Receipt. Purchase at your Post Office.
Present for mailing to a Postal employee if a postmarked sender’s receipt is requested. Combine with Return Receipt to get physical delivery record showing the recipient’s signature. Cost: $3.45
Return Receipt - "Get a hardcopy delivery record showing the recipient’s signature." Purchase at a Post Office. Cost: $2.75 for mail receipt (green postcard).
e) I like to get the little green postcard in the mail with a signature on it when I send something Certified, Return Receipt Requested, although you can opt for an electronic record of receipt if you prefer.
VA has made it much easier to review your Department of Veterans Affairs medical record with the advent of MyHealtheVet (MHV). You can also send your doctors a secure message via MHV.
On VA websites, you will see it written as "My HealtheVet", but you will also see the combined version, MyHealtheVet, which is how people say it.
The italicized e is serves a double function, first as the sound of the letter "y" (healthy) and second, it stands for "e", as in electronic (records).
You should regularly review your Department of Veterans Affairs medical record for at least these seven reasons.
1. Make sure you remember your doctor's recommendations, including anything you were supposed to do.
Example: "Am I supposed to fast for 12 hours before my lab test tomorrow?"
2. Double check the "dosing schedule" for your medications.
Example: "Did the pharmacy type this correctly on the label: 'Take two tablets twice a day, and then three tablets once a day'?"
3. Look up the name and dosage of a new medicine you're taking.
Example: "My private psychologist asked me the name of the new antidepressant I'm taking. I don't have my prescription bottle with me, but I can look it up on MyHealtheVet!"
4. Check lab test results.
Example: "I wonder if my cholesterol has gone down since I started this Paleo diet?"
5. Print out your medical records for a private doctor you will be seeing.
6. Review your VA medical records before filing a VA disability benefits claim.
Example: "I started getting depressed after I was diagnosed with cancer - even before I started radiation treatments and chemotherapy. When did the my doctor get the results of that biopsy back? Was last November or even earlier?"
7. To double check notes entered into your medical records by VA nurses, psychologists, physicians, and other clinicians to make sure everything is accurate. The sooner you catch an error, the easier it is to correct it.
Example: "I had an intake interview with a VA psychologist. He wrote down that I had been clean and sober for six weeks, but it's actually been six months. He did not write down that I attend AA and NA meetings 5 days a week; talk with my sponsor at least twice a week; and that I finished my 5th Step two weeks ago. I think that information is important!"
If you do not yet have a MyHealtheVet account, it is easier to Register for one online.
When you select on the registration form, Veteran, VA Patient, and after you submit the form, your account will automatically upgrade to an Advanced account.
You will then want to upgrade to a Premium account so that you can access all MyHealtheVet functions, including the Blue Button feature, which allows you to download your Department of Veterans Affairs medical record.
You might be able to upgrade to a MyHealtheVet Premium account online. If not, you can upgrade at a VA medical center and at most VA outpatient clinics.
MyHealtheVet is free for veterans, including the Advanced and Premium accounts.
If you don't have a computer or don't like to use them...
Or, if you're going to be going to your VA medical center anyway, stop by the MyHealtheVet office where they usually have computers you can use, and they'll teach you what you need to know.
Here are some additional guides, documents, and resources regarding your Department of Veterans Affairs medical record.
My HealtheVet/Secure Messaging/e-Benefits User Guide for Veterans - Created by the Salt Lake City VA Health Care System (VASLCHCS), this guide provides very helpful information for all veterans, regardless of your location.
The guide contains:
1. Amendment of records, 38 C.F.R. § 1.579 (2017).
2. Veterans Health Admin., Dep't Veterans Aff., VHA Directive 1605.01, § 8. Right to Request Amendment of Records, pp. 26–30, (2016).
3. Veterans Health Admin., Dep't Veterans Aff., VHA Handbook 1907.01 § 26 Health Record Alterations and Modification, pt. b, no. 4 Amendment, 32–35, (2015).
4. Id. (4)(a), at 32 ("Amendment is the alteration of health information by modification, correction, addition or deletion at the request of the patient or Veteran. A request to amend any data contained in VA health records must be submitted in writing to the facility Privacy Officer, or designee, by the patient or Veteran stating explicitly what information is in contention and why, i.e., inaccurate or erroneous, irrelevant, untimely, or incomplete.")
5. If you do not have a middle name, use "NMN" for "No Middle Name", e.g., John NMN Smith.
6. In my experience, VA medical center websites do not provide much information, and the search engine on all va.gov sites is abysmal. On the other hand, if someone usually answers the phone promptly at your VAMC, then you can call to see if the operator can find the Privacy Officer's name and exact mailing address, if you wish.