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Initial vault setup

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- VA strategy documents for Fred
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# Template: Doctor Letter for Kobe's VA Dependent Benefits Claim
**Purpose:** This template provides the structure for a medical professional to write a letter supporting Kobe's VA dependent benefits claim. Give this to Kobe's doctor to complete.
**Critical Elements:** The letter MUST state that Kobe is "permanently incapable of self-support" due to disability that existed before age 18.
---
## Instructions for Doctor
**Dear Dr. [Name],**
I am requesting a letter to support a VA dependent benefits claim for my son, **[Kobe's Full Name]**, who has a permanent disability.
**The Department of Veterans Affairs requires a medical opinion letter that includes:**
1. Your professional credentials and relationship to my son
2. His diagnoses (with ICD-10 codes if possible)
3. When the disability began (ideally before age 18)
4. Description of functional limitations
5. Your medical opinion that he is **"permanently incapable of self-support"**
6. The basis for your opinion
**I have provided a template below that you can use or adapt. Please write this on your professional letterhead if possible.**
**If you have any questions, the VA can be reached at 1-800-827-1000, or you can contact me at [your phone/email].**
Thank you for your assistance with this important matter.
Sincerely,
Frederick Book
---
## TEMPLATE LETTER (For Doctor to Complete on Letterhead)
**[Doctor's Letterhead]**
**Date:** [Current Date]
**To Whom It May Concern:**
**RE: Medical Opinion for VA Dependent Benefits**
**Patient Name:** [Kobe's Full Legal Name]
**Date of Birth:** [MM/DD/YYYY]
**Patient ID / Medical Record #:** [if applicable]
I am writing this letter to provide a medical opinion regarding [Kobe's first name]'s permanent disability in support of his father's application for VA dependent benefits.
---
### I. PHYSICIAN CREDENTIALS & RELATIONSHIP TO PATIENT
**My name is [Doctor's Full Name], and I am a board-certified [specialty] licensed to practice medicine in the state of [state].**
**Professional Credentials:**
- Medical Degree: [Institution, Year]
- Board Certification: [Specialty, Year]
- License Number: [State License #]
- Current Practice: [Clinic/Hospital Name, City, State]
- Years in Practice: [number]
**Relationship to Patient:**
- I have been [Kobe's] [treating physician / specialist] since [date/year]
- I have personally examined [Kobe] on [number] occasions
- Most recent examination: [date]
- I have reviewed his complete medical history including records from [list key providers]
---
### II. DIAGNOSES
**[Kobe] has been diagnosed with the following conditions:**
**Primary Diagnoses:**
1. **[Diagnosis Name]** (ICD-10: [code]) - Diagnosed: [date/year]
2. **[Diagnosis Name]** (ICD-10: [code]) - Diagnosed: [date/year]
3. **[Diagnosis Name]** (ICD-10: [code]) - Diagnosed: [date/year]
**Secondary/Associated Conditions:**
4. [Diagnosis] (ICD-10: [code])
5. [Diagnosis] (ICD-10: [code])
**[Choose relevant examples to include below:]**
*For Autism Spectrum Disorder:*
"[Kobe] meets DSM-5 criteria for Autism Spectrum Disorder, Level [2 or 3] - [Requiring substantial support / Requiring very substantial support]. This diagnosis was confirmed through comprehensive evaluation including [ADOS-2, ADI-R, clinical observation, etc.] and is consistent with observed deficits in social communication, restricted interests, and sensory processing."
*For Intellectual Disability:*
"[Kobe] meets DSM-5 criteria for Intellectual Disability (Intellectual Developmental Disorder), with severity level of [Mild / Moderate / Severe]. Psychological testing reveals a Full Scale IQ of [score], placing him in the [percentile] percentile, more than [number] standard deviations below the mean. Additionally, adaptive functioning is significantly impaired, as evidenced by [Vineland/ABAS] scores of [score] in [domains]."
*For Cerebral Palsy:*
"[Kobe] has been diagnosed with Cerebral Palsy, [type], affecting [body areas]. This is classified as GMFCS Level [I-V] and MACS Level [I-V], indicating [description of functional motor limitations]."
*For Seizure Disorder:*
"[Kobe] has a documented seizure disorder, specifically [type of seizures], that is [well-controlled / partially controlled / refractory] on current medication regimen of [medications]. EEG findings show [abnormalities]. Despite treatment, he experiences [frequency] seizures and requires constant supervision for safety."
*For Genetic Disorders:*
"[Kobe] has been diagnosed with [genetic condition name], confirmed by genetic testing showing [specific mutation/chromosomal abnormality]. This condition is associated with intellectual disability, developmental delays, and medical complications including [list]."
---
### III. ONSET & DEVELOPMENTAL HISTORY
**[Kobe's] disability was present from [early childhood / birth / age X].**
**Developmental History:**
- Parents first noted concerns about [Kobe's] development at approximately [age/timeframe]
- Early signs included [developmental delays in motor skills / lack of speech / social deficits / etc.]
- He did not meet typical developmental milestones, including [specific examples: walking, talking, toilet training, etc.]
- Early intervention services began at age [X], and he has required continuous special education and therapeutic services since that time
**The medical evidence demonstrates that [Kobe's] disability has been present since [before age 18 / early childhood], is permanent in nature, and has persisted despite extensive intervention and treatment.**
---
### IV. FUNCTIONAL LIMITATIONS
**[Kobe's] disability results in significant and permanent functional limitations across multiple domains:**
#### A. Activities of Daily Living (ADLs)
**Personal Care:**
- [Kobe] requires [complete / substantial / constant supervision for] assistance with bathing, dressing, grooming, and toileting
- He cannot [specific examples: tie shoes, button shirts, manage zippers]
- He requires verbal prompting and physical assistance to complete basic self-care tasks
- He lacks the judgment to maintain personal hygiene independently
**Eating:**
- Requires supervision during meals due to [choking risk / inability to prepare food / limited food tolerance]
- Cannot safely prepare food or use kitchen appliances
- [Does not recognize hunger/fullness cues / Has extremely restricted diet due to sensory issues]
**Toileting:**
- [Requires reminders / Has frequent accidents / Not fully continent]
- Cannot manage hygiene independently
- Requires nighttime monitoring due to [bedwetting / safety concerns]
#### B. Communication & Social Functioning
**Communication:**
- [Kobe's] expressive language is significantly delayed, functioning at approximately [age]-year-old level despite being [actual age]
- He cannot [hold reciprocal conversation / answer open-ended questions / express complex needs]
- Receptive language is also impaired; he can follow only [simple one-step / no more than two-step] directions
- He requires [AAC device / visual supports / simplified language] to communicate
**Social Interaction:**
- [Kobe] demonstrates severe deficits in social interaction
- He does not initiate social contact with peers
- He lacks understanding of social norms, personal boundaries, and age-appropriate behavior
- He cannot form or maintain peer friendships
- He requires constant adult supervision in social settings
#### C. Safety & Judgment
- [Kobe] has severely impaired judgment and lacks understanding of danger
- He requires 24-hour supervision for his safety
- He has [wandered / engaged in dangerous behaviors such as _____]
- He cannot be left alone for any period of time without risk of injury
- He does not recognize potentially harmful situations such as [traffic, strangers, hot surfaces, etc.]
#### D. Cognitive & Learning
**Current Educational Status:**
- [Kobe] receives special education services under [full-time special education / general education with substantial supports]
- His cognitive functioning is in the [range] with IQ testing showing Full Scale IQ of [score]
- Academic skills are [number] grade levels below age expectation
- He requires [1:1 aide / small group instruction / modified curriculum]
- He cannot complete academic tasks without constant redirection and support
**Adaptive Functioning:**
- Standardized adaptive behavior assessment ([Vineland / ABAS]) reveals:
- Communication: [age equivalent / standard score]
- Daily Living Skills: [age equivalent / standard score]
- Socialization: [age equivalent / standard score]
- Overall Adaptive Behavior Composite: [score], classified as [Low / Extremely Low]
- These scores indicate functioning significantly below age expectations across all adaptive domains
#### E. Behavioral & Emotional Regulation
- [Kobe] has significant difficulty with emotional regulation
- He experiences [frequent meltdowns / aggressive behaviors / self-injurious behaviors]
- These behaviors occur [frequency] and can last [duration]
- He requires behavioral intervention and cannot manage emotions independently
- His behaviors create safety concerns and limit his ability to participate in community activities
---
### V. TREATMENT HISTORY & RESPONSE
**[Kobe] has received extensive interventions including:**
**Therapeutic Services:**
- Speech-Language Therapy: [frequency, duration, progress]
- Occupational Therapy: [frequency, duration, progress]
- Physical Therapy: [if applicable]
- ABA/Behavioral Therapy: [if applicable]
- Other: [list any other therapies]
**Educational Interventions:**
- Special education services since age [X]
- Individualized Education Program (IEP) with [describe level of support]
- [List specific interventions, accommodations, modifications]
**Medical Management:**
- Medications: [list current medications and purpose]
- Other medical interventions: [as applicable]
**Response to Treatment:**
Despite years of intensive therapeutic intervention, educational support, and medical management, [Kobe] has made [minimal / limited / some] progress in functional skills. **The gap between his functional abilities and those of typical peers has [widened / remained significant] over time.** He continues to require the same level of support and supervision, and there is no expectation that he will achieve independence in adulthood.
---
### VI. PROGNOSIS
**[Kobe's] disability is permanent and lifelong in nature.**
**The following factors support permanence:**
1. **Neurological/biological basis:** [His conditions are neurologically-based and result from [developmental brain differences / genetic factors / prenatal injury / etc.]]
2. **Lack of progress despite intervention:** Despite years of intensive therapy and education, fundamental limitations persist
3. **Nature of diagnosis:** [Autism Spectrum Disorder / Intellectual Disability / Cerebral Palsy / etc.] is a permanent, non-curable condition
4. **Age and developmental trajectory:** At age [X], with persistent functional limitations and lack of developmental progress, the prognosis for independence is extremely poor
**Expected Future Functioning:**
- [Kobe] will not be capable of living independently as an adult
- He will require supervised living arrangements and ongoing support with all activities of daily living
- He will not be capable of competitive employment or self-support
- He will require lifelong assistance with personal care, safety supervision, and decision-making
- He will need continued medical management, therapeutic services, and educational/vocational support
---
### VII. MEDICAL OPINION
**Based on my examination of [Kobe], review of his medical and educational records, knowledge of his diagnoses, and my [number] years of experience treating patients with similar conditions, it is my medical opinion that:**
**[Kobe Full Name] is permanently incapable of self-support due to [his diagnoses].**
**This disability existed before age 18 and will persist throughout his lifetime. He will require lifelong care, supervision, and financial support from his family or other care providers.**
**The functional limitations described in this letter are permanent and are not expected to improve with further intervention. [Kobe] meets the criteria for dependent benefits based on permanent and total disability.**
---
### VIII. BASIS FOR OPINION
My opinion is based on:
1. Direct personal examination and treatment of [Kobe] over [time period]
2. Review of comprehensive medical records from [providers]
3. Review of educational records including IEP and psychoeducational evaluations
4. Review of standardized testing results including:
- Cognitive testing (IQ: [score])
- Adaptive behavior assessment (Composite: [score])
- Academic achievement testing
- [Other relevant assessments]
5. Parental report of functional limitations in home and community settings
6. Reports from therapists, teachers, and other professionals involved in [Kobe's] care
7. My clinical experience and expertise in [specialty]
8. Medical literature regarding prognosis for [diagnoses]
---
### IX. SUPPORTING DOCUMENTATION
I am providing the following additional documentation to support this opinion:
- [ ] Recent medical records from my practice
- [ ] Copies of diagnostic reports
- [ ] Psychological/neuropsychological evaluation reports
- [ ] Adaptive behavior assessment results
- [ ] [Other relevant documents]
---
### X. AVAILABILITY FOR FURTHER INFORMATION
I am available to provide additional information or clarification if needed by the Department of Veterans Affairs. I can be reached at:
**[Doctor Name], [Credentials]**
**[Clinic/Hospital Name]**
**[Address]**
**[City, State ZIP]**
**Phone:** [Office Phone]
**Fax:** [Fax Number]
**Email:** [Professional Email]
---
**Signature:** ___________________________________
**Printed Name:** [Doctor's Full Name, MD/DO/PhD, etc.]
**Title:** [Specialty]
**Date:** _____________________
**Medical License #:** [State License Number]
**NPI #:** [National Provider Identifier]
---
## END OF TEMPLATE
---
## Notes for Fred
**Customizing this template:**
1. **Fill in all bracketed fields** with Kobe's specific information before giving to doctor
2. **Choose relevant sections** - delete examples that don't apply to Kobe
3. **Provide supporting context** - give doctor copies of:
- Recent IEP
- Recent testing results (IQ, adaptive behavior)
- Therapy reports
- Your lay statement (so doctor can reference your observations)
**Key phrases the letter MUST include:**
- ✅ "Permanently incapable of self-support"
- ✅ "Disability existed before age 18"
- ✅ "Permanent and lifelong in nature"
- ✅ "Will require lifelong care and supervision"
- ✅ "Not expected to achieve independence"
**What makes a strong letter:**
- Detailed description of functional limitations (not just diagnosis)
- Comparison to typical peers
- Documentation of lack of progress despite treatment
- Clear statement about permanence
- Explanation of medical/biological basis for permanence
- Doctor's credentials and expertise
**If doctor is hesitant:**
- Emphasize you're asking for their honest medical opinion
- Explain VA needs specific language about "self-support"
- Offer to provide additional documentation they need
- Remind them this is standard for VA dependent benefits
- They're NOT committing fraud - they're documenting reality
**Multiple doctors:**
If Kobe sees multiple specialists, consider getting letters from:
- Primary care doctor (overall picture)
- Developmental pediatrician or neurologist (diagnosis + prognosis)
- Psychiatrist/psychologist (cognitive + adaptive functioning)
Multiple letters can strengthen the claim, but one strong letter from a credible provider is better than several weak letters.
---
**This template is ready to customize for Kobe and present to his doctor.**

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# Kobe VA Dependent Benefits: Complete Documentation Checklist
**Purpose:** Master checklist for gathering all documentation needed for VA dependent benefits claim. Use this to track progress and ensure nothing is missed.
**Claim Goal:** Establish that Kobe has a permanent disability that existed before age 18, rendering him incapable of self-support.
---
## CLAIM TIMELINE TRACKER
| Milestone | Target Date | Actual Date | Status |
|-----------|-------------|-------------|--------|
| Records requests sent | ___/___/___ | ___/___/___ | [ ] |
| Doctor appointment scheduled | ___/___/___ | ___/___/___ | [ ] |
| All medical records received | ___/___/___ | ___/___/___ | [ ] |
| Lay statement completed | ___/___/___ | ___/___/___ | [ ] |
| Doctor letter obtained | ___/___/___ | ___/___/___ | [ ] |
| Complete package compiled | ___/___/___ | ___/___/___ | [ ] |
| VA Form 21-686c completed | ___/___/___ | ___/___/___ | [ ] |
| Claim submitted to VA | ___/___/___ | ___/___/___ | [ ] |
| VA acknowledgment received | ___/___/___ | ___/___/___ | [ ] |
| C&P exam scheduled (if needed) | ___/___/___ | ___/___/___ | [ ] |
| Decision received | ___/___/___ | ___/___/___ | [ ] |
---
## SECTION 1: VA FORMS & OFFICIAL DOCUMENTS
### Required Forms
**Primary Form:**
- [ ] **VA Form 21-686c** - Declaration of Status of Dependents
- Available: https://www.va.gov/find-forms/about-form-21-686c/
- Can file online via eBenefits or VA.gov
- Or mail paper form to regional office
- **Key sections for disabled child:**
- Part III, Section B: Information about helpless child
- Must answer questions about child's disability
- Requires doctor signature in certain cases
**Additional Forms (may be needed):**
- [ ] **VA Form 21-4138** - Statement in Support of Claim
- Use this to submit lay statement if needed
- Can also be used for additional explanatory information
- [ ] **VA Form 21-0788** - Authorization to Disclose Information
- Allows VA to request medical records directly
- Fill out for each medical provider
- [ ] **VA Form 21-4142** - Authorization for Release of Information
- Another authorization form for medical records
- Use if providers require specific VA form
**Identity Documents:**
- [ ] Kobe's birth certificate (certified copy)
- [ ] Kobe's Social Security card (copy)
- [ ] Your DD-214 (if not already in VA file)
- [ ] Proof of your VA disability rating (award letter)
**Status:**
- Forms obtained: [ ]
- Forms completed: [ ]
- Forms ready to submit: [ ]
---
## SECTION 2: MEDICAL RECORDS
**Purpose:** Establish medical history, diagnoses, and permanence of disability
### A. Primary Care Records
**Pediatrician/Family Doctor:**
- [ ] **Provider:** [Name] ________________________
- [ ] Address/Contact: _______________________
- [ ] Request sent: ___/___/___
- [ ] Records received: ___/___/___
- [ ] **Date range:** [Start] to [End]
**What to request:**
- [ ] Complete medical history
- [ ] Well-child visit notes
- [ ] Growth and developmental screening results
- [ ] Referral letters to specialists
- [ ] Immunization records
- [ ] Any developmental delay documentation
**Additional Primary Care Providers:**
- [ ] **Provider:** [Name] ________________________
- [ ] Records sent: ___/___/___ | Received: ___/___/___
### B. Specialist Records
**Developmental Pediatrician:**
- [ ] **Provider:** [Name] ________________________
- [ ] Request sent: ___/___/___ | Received: ___/___/___
- [ ] **Key documents:**
- [ ] Developmental assessments
- [ ] Diagnosis documentation
- [ ] Functional assessments
- [ ] Treatment recommendations
**Neurologist (if applicable):**
- [ ] **Provider:** [Name] ________________________
- [ ] Request sent: ___/___/___ | Received: ___/___/___
- [ ] **Key documents:**
- [ ] Neurological exam results
- [ ] Brain imaging (MRI, CT, EEG)
- [ ] Seizure documentation
- [ ] Medication management notes
**Psychiatrist/Psychologist:**
- [ ] **Provider:** [Name] ________________________
- [ ] Request sent: ___/___/___ | Received: ___/___/___
- [ ] **Key documents:**
- [ ] Psychological evaluation reports
- [ ] IQ testing results
- [ ] Adaptive behavior assessments (Vineland, ABAS)
- [ ] Diagnostic assessments (ADOS for autism, etc.)
- [ ] Cognitive functioning reports
**Geneticist (if applicable):**
- [ ] **Provider:** [Name] ________________________
- [ ] Request sent: ___/___/___ | Received: ___/___/___
- [ ] **Key documents:**
- [ ] Genetic testing results
- [ ] Chromosomal analysis
- [ ] Syndrome diagnosis documentation
### C. Therapy Records
**Speech-Language Pathologist:**
- [ ] **Provider:** [Name] ________________________
- [ ] Request sent: ___/___/___ | Received: ___/___/___
- [ ] **Key documents:**
- [ ] Initial evaluation
- [ ] Progress notes
- [ ] Standardized test results (CELF, PPVT, etc.)
- [ ] Current functional level
**Occupational Therapist:**
- [ ] **Provider:** [Name] ________________________
- [ ] Request sent: ___/___/___ | Received: ___/___/___
- [ ] **Key documents:**
- [ ] Sensory processing evaluations
- [ ] Fine motor assessments
- [ ] Self-care skills evaluations
- [ ] ADL functioning reports
**Physical Therapist (if applicable):**
- [ ] **Provider:** [Name] ________________________
- [ ] Request sent: ___/___/___ | Received: ___/___/___
- [ ] **Key documents:**
- [ ] Gross motor assessments
- [ ] Mobility evaluations
- [ ] Equipment needs documentation
**Behavioral/ABA Therapist:**
- [ ] **Provider:** [Name] ________________________
- [ ] Request sent: ___/___/___ | Received: ___/___/___
- [ ] **Key documents:**
- [ ] Functional behavior assessments
- [ ] Behavior intervention plans
- [ ] Progress data
- [ ] Adaptive skill assessments
### D. Hospital/Emergency Records
- [ ] **Facility:** [Hospital Name] ________________
- [ ] **Dates of service:** _____________________
- [ ] **Reason:** (birth records, ER visits, admissions)
- [ ] Request sent: ___/___/___ | Received: ___/___/___
**What to request:**
- [ ] Birth records (especially if complications)
- [ ] Newborn screening results
- [ ] ER visit records (head injuries, seizures, etc.)
- [ ] Inpatient admission records
- [ ] Surgical records (if any)
**Additional facilities:**
- [ ] **Facility:** _____________ | Sent: ___/___ | Received: ___/___
- [ ] **Facility:** _____________ | Sent: ___/___ | Received: ___/___
---
## SECTION 3: EDUCATIONAL RECORDS
**Purpose:** Document educational impact and need for special services
### A. School Records
**Current School:**
- [ ] **School:** [Name] ________________________
- [ ] **Contact:** [Special Ed Coordinator] ____________
- [ ] Request sent: ___/___/___ | Received: ___/___/___
**What to request:**
- [ ] **Current IEP (Individualized Education Program)**
- [ ] Present levels of performance
- [ ] Goals and objectives
- [ ] Services provided (hours/type)
- [ ] Accommodations and modifications
- [ ] Most recent progress reports
- [ ] **All previous IEPs** (every year)
- Shows progression and long-term needs
- [ ] **Initial evaluation for special education**
- Documents when disability was first identified by school
- Often includes comprehensive testing
- [ ] **All re-evaluations** (typically every 3 years)
- [ ] Psychoeducational evaluation
- [ ] Academic achievement testing
- [ ] Cognitive/IQ testing
- [ ] Adaptive behavior assessment
- [ ] Functional behavior assessment
- [ ] **Report cards** (all years)
- Shows academic functioning
- [ ] **Progress reports** (IEP goal progress)
- [ ] **504 Plan** (if applicable, before IEP)
- [ ] **Discipline records**
- Behavioral incident reports
- Suspensions or removals from class
- [ ] **Attendance records**
- May show pattern of school avoidance or medical absences
**Previous Schools:**
- [ ] **School:** _____________ | Sent: ___/___ | Received: ___/___
- [ ] **School:** _____________ | Sent: ___/___ | Received: ___/___
### B. Early Intervention Records
**Birth to Age 3:**
- [ ] **Program:** [Name] ________________________
- [ ] Request sent: ___/___/___ | Received: ___/___/___
**What to request:**
- [ ] Initial IFSP (Individualized Family Service Plan)
- [ ] All IFSP updates
- [ ] Evaluation reports
- [ ] Service provider notes
- [ ] Developmental assessments
- [ ] Transition plan to preschool
**Age 3-5 (Preschool):**
- [ ] **Program:** [Name] ________________________
- [ ] Request sent: ___/___/___ | Received: ___/___/___
**What to request:**
- [ ] Preschool IEP
- [ ] Developmental assessments
- [ ] Readiness evaluations
---
## SECTION 4: DIAGNOSTIC ASSESSMENTS
**Purpose:** Formal testing that documents disability severity
### Key Assessments to Obtain
**Intellectual/Cognitive:**
- [ ] **IQ Testing** (WISC, WAIS, Stanford-Binet, etc.)
- [ ] Test name: ___________________
- [ ] Date administered: ___/___/___
- [ ] Full Scale IQ: _____
- [ ] Verbal IQ: _____
- [ ] Performance IQ: _____
- [ ] Where obtained: _________________
- [ ] Copy in file: [ ]
**Adaptive Functioning:**
- [ ] **Vineland Adaptive Behavior Scales**
- [ ] Date: ___/___/___ | Score: _____ | Copy: [ ]
- [ ] **ABAS (Adaptive Behavior Assessment System)**
- [ ] Date: ___/___/___ | Score: _____ | Copy: [ ]
- [ ] **Other:** ___________________
- [ ] Date: ___/___/___ | Score: _____ | Copy: [ ]
**Academic Achievement:**
- [ ] **WIAT (Wechsler Individual Achievement Test)**
- [ ] Date: ___/___/___ | Reading: ___ | Math: ___ | Copy: [ ]
- [ ] **Woodcock-Johnson**
- [ ] Date: ___/___/___ | Scores: _________ | Copy: [ ]
- [ ] **Other:** ___________________
**Autism Screening (if applicable):**
- [ ] **ADOS-2** (Autism Diagnostic Observation Schedule)
- [ ] Date: ___/___/___ | Result: _________ | Copy: [ ]
- [ ] **ADI-R** (Autism Diagnostic Interview-Revised)
- [ ] Date: ___/___/___ | Result: _________ | Copy: [ ]
- [ ] **M-CHAT** (Modified Checklist for Autism in Toddlers)
- [ ] Date: ___/___/___ | Result: _________ | Copy: [ ]
**Speech/Language:**
- [ ] **CELF** (Clinical Evaluation of Language Fundamentals)
- [ ] Date: ___/___/___ | Scores: _________ | Copy: [ ]
- [ ] **PPVT** (Peabody Picture Vocabulary Test)
- [ ] Date: ___/___/___ | Score: _____ | Copy: [ ]
**Other Relevant Testing:**
- [ ] **Test:** ___________ | Date: ___/___ | Result: _____ | Copy: [ ]
- [ ] **Test:** ___________ | Date: ___/___ | Result: _____ | Copy: [ ]
---
## SECTION 5: STATEMENTS & LETTERS
### A. Medical Opinion Letter (CRITICAL)
**Doctor to complete letter stating:**
- [ ] **Provider:** [Name of doctor] ________________________
- [ ] Specialty: _____________________
- [ ] **Letter requested:** ___/___/___
- [ ] **Letter received:** ___/___/___
**Letter must include:**
- [ ] Child's diagnoses (with ICD codes)
- [ ] When disability began (preferably before age 18)
- [ ] Nature and severity of disability
- [ ] Functional limitations in clear terms
- [ ] Prognosis (permanent vs. temporary)
- [ ] Opinion: Child is "permanently incapable of self-support"
- [ ] Medical basis for opinion
- [ ] Doctor's credentials and relationship to child
**Use the template:** `kobe-va-doctor-letter-template.md`
### B. Parent Lay Statement
- [ ] **Lay statement completed:** ___/___/___
- [ ] **Reviewed and revised:** ___/___/___
- [ ] **Signed and dated:** ___/___/___
**Use the template:** `kobe-va-lay-statement-template.md`
**Key elements included:**
- [ ] Specific examples of functional limitations
- [ ] Comparison to typical children same age
- [ ] Daily care requirements described
- [ ] Safety concerns documented
- [ ] Educational impact explained
- [ ] Social functioning described
- [ ] Family impact included
- [ ] Permanence emphasized
### C. Third-Party Statements (OPTIONAL BUT HELPFUL)
**Teacher/School Staff:**
- [ ] **Name:** _____________ | **Role:** _____________
- [ ] Statement requested: ___/___/___
- [ ] Statement received: ___/___/___
**Therapist:**
- [ ] **Name:** _____________ | **Type:** _____________
- [ ] Statement requested: ___/___/___
- [ ] Statement received: ___/___/___
**Other Family Members:**
- [ ] **Name:** _____________ | **Relationship:** _____________
- [ ] Statement completed: ___/___/___
**What they should address:**
- Their relationship to child and how long they've known him
- Specific observations of limitations
- How child compares to others they work with
- Prognosis based on their professional judgment
---
## SECTION 6: FINANCIAL DOCUMENTATION
**Purpose:** May be needed to show child is not self-supporting
- [ ] **Proof child lives with you:**
- [ ] Lease/mortgage showing child's name or your address
- [ ] School enrollment showing your address
- [ ] Medical records showing your address
- [ ] **Proof you provide financial support:**
- [ ] Bank statements showing expenses for child
- [ ] Medical bills in child's name
- [ ] Receipts for therapy, equipment, medications
- [ ] **Proof child has no income:**
- [ ] Statement that child receives no SSI/SSDI
- [ ] Or copy of SSI award letter (doesn't disqualify from VA benefits)
- [ ] Documentation child is not employed
---
## SECTION 7: SUPPORTING EVIDENCE COMPILATION
### Evidence Categories
**A. Diagnosis Evidence**
- [ ] Organized by condition (autism, intellectual disability, etc.)
- [ ] Earliest documentation first
- [ ] Shows progression over time
- [ ] Includes formal diagnostic reports
**B. Functional Limitation Evidence**
- [ ] ADL assessments
- [ ] Adaptive behavior testing
- [ ] School functional assessments
- [ ] Therapy progress notes showing limitations
- [ ] IEP present levels of performance
**C. Permanence Evidence**
- [ ] Early childhood diagnoses
- [ ] Lack of progress despite intervention
- [ ] Doctor statements about prognosis
- [ ] Progressive worsening (if applicable)
- [ ] Genetic diagnoses (if applicable)
**D. Timeline Documentation**
- [ ] Create a chronological timeline showing:
- When first concerns arose
- When diagnoses were made
- What interventions were tried
- Current status
- [ ] Emphasizes: "This started before age 18 and is permanent"
---
## SECTION 8: ORGANIZATION & SUBMISSION
### A. Document Organization
**Create binder or digital folders with:**
1. **Section 1: Forms**
- [ ] VA Form 21-686c (completed)
- [ ] VA Form 21-4138 (if using for lay statement)
- [ ] Other VA forms
2. **Section 2: Identity Documents**
- [ ] Birth certificate
- [ ] Social Security card
- [ ] Your VA documents
3. **Section 3: Medical Opinion Letter**
- [ ] Doctor's letter (THE MOST IMPORTANT DOCUMENT)
4. **Section 4: Parent Lay Statement**
- [ ] Your detailed statement
5. **Section 5: Medical Records**
- [ ] Organized by provider
- [ ] Chronological within each provider
- [ ] Tab dividers between providers
6. **Section 6: Educational Records**
- [ ] Most recent IEP first
- [ ] Then previous IEPs in reverse chronological order
- [ ] Evaluation reports
7. **Section 7: Testing & Assessments**
- [ ] Psychological evaluations
- [ ] IQ testing
- [ ] Adaptive behavior assessments
- [ ] Academic testing
8. **Section 8: Third-Party Statements**
- [ ] Teacher statements
- [ ] Therapist statements
- [ ] Other supporting letters
9. **Section 9: Timeline & Summary**
- [ ] Create one-page timeline of key dates
- [ ] Brief summary of evidence
### B. Document Preparation
- [ ] **Make copies:**
- [ ] Keep original documents
- [ ] Submit copies to VA (unless they require originals)
- [ ] Keep second set of copies for your records
- [ ] **Organize chronologically:**
- [ ] Oldest documents first or most recent first (be consistent)
- [ ] **Label everything:**
- [ ] Write child's name and DOB on every page
- [ ] Number pages if submitting large packet
- [ ] **Create index:**
- [ ] List of all documents being submitted
- [ ] Where each can be found (page numbers)
### C. Submission Methods
**Option 1: Online** (fastest)
- [ ] Via VA.gov or eBenefits
- [ ] Upload documents as PDFs
- [ ] Receive immediate confirmation
- [ ] Can track status online
**Option 2: Mail**
- [ ] Send to VA Regional Office
- [ ] Use certified mail, return receipt requested
- [ ] Keep proof of mailing
- [ ] Allow 7-10 business days for processing
**Option 3: In Person**
- [ ] Regional office or VA medical center
- [ ] Get stamped copy as proof of filing
- [ ] Can ask questions in person
**Submission details:**
- [ ] **Method chosen:** _______________
- [ ] **Date submitted:** ___/___/___
- [ ] **Confirmation received:** ___/___/___
- [ ] **Claim number assigned:** _______________
---
## SECTION 9: POST-SUBMISSION TRACKING
### A. Initial Processing
- [ ] **VA acknowledgment received:** ___/___/___
- [ ] **Claim number:** _______________
- [ ] **Assigned Regional Office:** _______________
- [ ] **Expected decision timeframe:** _______________
### B. Development (if VA requests more info)
- [ ] **Request for additional evidence:** ___/___/___
- [ ] What they want: _____________________
- [ ] Deadline: ___/___/___
- [ ] Submitted: ___/___/___
- [ ] **C&P Exam scheduled** (Compensation & Pension exam)
- [ ] Date: ___/___/___ | Time: _____ | Location: _________
- [ ] Type: (In-person / Telehealth / Records review)
- [ ] Examiner: _____________________
- [ ] Exam completed: ___/___/___
- [ ] **Bring to exam:**
- [ ] Photo ID
- [ ] List of current medications
- [ ] Summary of functional limitations
- [ ] Any recent medical records not yet submitted
### C. Decision
- [ ] **Decision letter received:** ___/___/___
- [ ] **Decision:** (Approved / Denied / Deferred)
- [ ] **Effective date:** ___/___/___
- [ ] **Monthly benefit amount:** $_________
**If Approved:**
- [ ] First payment received: ___/___/___
- [ ] Set up direct deposit if not already done
- [ ] Understand reporting requirements (child's status changes)
**If Denied:**
- [ ] Read denial letter carefully
- [ ] Note reasons for denial
- [ ] Deadline to appeal: ___/___/___ (1 year from decision)
- [ ] Decide: (Gather more evidence / File appeal / Request HLR / Supplemental claim)
---
## SECTION 10: COMMON PITFALLS & HOW TO AVOID THEM
### ❌ Missing Critical Evidence
**Problem:** "I didn't know I needed that"
**Solution:** This checklist! Submit everything, let VA decide what's relevant
### ❌ Vague Statements
**Problem:** "He has problems with daily living"
**Solution:** "He cannot dress himself, requires assistance bathing, and cannot prepare any food"
### ❌ No Doctor Letter
**Problem:** Submitted only medical records, no clear opinion
**Solution:** Get explicit letter stating "permanently incapable of self-support"
### ❌ Missing Permanence
**Problem:** Didn't emphasize disability is lifelong
**Solution:** Include prognosis, show early onset, document lack of progress
### ❌ No Comparison to Peers
**Problem:** Didn't show how child differs from typical children
**Solution:** Include adaptive behavior testing, educational evaluations
### ❌ Too Much Medical Jargon
**Problem:** Submitted only doctor notes full of terminology
**Solution:** Include parent lay statement in plain English
### ❌ Gaps in Timeline
**Problem:** Missing years of records
**Solution:** Create timeline explaining gaps, submit statement if records unavailable
### ❌ Insufficient Functional Evidence
**Problem:** Proves diagnosis but not impact
**Solution:** Focus on what child CANNOT do, need for supervision, ADL limitations
---
## SECTION 11: QUICK REFERENCE
### Absolute Must-Haves (Cannot file without these)
1. ✅ **VA Form 21-686c** (Declaration of Status of Dependents)
2. ✅ **Birth certificate** (proves age and relationship)
3. ✅ **Medical evidence of disability** (diagnosis + functional impact)
### Extremely Important (Claim likely fails without these)
4. ✅ **Doctor letter with clear opinion** (permanently incapable of self-support)
5. ✅ **Proof disability began before age 18**
6. ✅ **Evidence of functional limitations** (IEP, adaptive behavior testing, therapy notes)
### Very Helpful (Strengthens claim significantly)
7. ✅ **Parent lay statement** (your detailed observations)
8. ✅ **IEP and school records** (educational impact)
9. ✅ **Adaptive behavior assessment** (Vineland, ABAS showing scores)
10. ✅ **Early childhood records** (shows permanence)
### Nice to Have (Additional support)
11. ✅ Third-party statements (teachers, therapists)
12. ✅ Photos or videos showing functional limitations
13. ✅ Financial documentation of care costs
---
## SECTION 12: KEY CONTACT INFORMATION
**VA Resources:**
- **VA Benefits Hotline:** 1-800-827-1000
- **eBenefits:** https://www.ebenefits.va.gov/
- **VA.gov:** https://www.va.gov/
- **MyHealtheVet:** https://www.myhealth.va.gov/
**Your VA Information:**
- **Regional Office:** _______________
- **File Number / VA Claim Number:** _______________
- **eBenefits Username:** _______________
**Your VSO (Veterans Service Organization):**
- **Organization:** (DAV, VFW, American Legion, etc.) _______________
- **VSO Name:** _______________
- **Phone:** _______________
- **Email:** _______________
**Key Medical Providers:**
- **Primary Doctor:** _____________ | Phone: _____________
- **Specialist:** _____________ | Phone: _____________
- **Therapist:** _____________ | Phone: _____________
**Key School Contacts:**
- **Special Ed Coordinator:** _____________ | Phone: _____________
- **IEP Case Manager:** _____________ | Phone: _____________
---
## SECTION 13: NOTES & REMINDERS
**Document any issues, questions, or important information here:**
**___/___/___** -
_________________________________________________________________
_________________________________________________________________
**___/___/___** -
_________________________________________________________________
_________________________________________________________________
**___/___/___** -
_________________________________________________________________
_________________________________________________________________
---
## FINAL CHECKLIST BEFORE SUBMISSION
**Review this right before you mail/upload:**
- [ ] VA Form 21-686c completed and signed
- [ ] All required identity documents included
- [ ] Doctor letter explicitly states "permanently incapable of self-support"
- [ ] Parent lay statement is detailed and specific
- [ ] Medical records show diagnoses with dates
- [ ] Evidence shows disability existed before age 18
- [ ] Functional limitations are well-documented
- [ ] IEP or educational evaluations included
- [ ] All documents have child's name and DOB on them
- [ ] Made copies of everything for my records
- [ ] Know where I'm submitting (online/mail/in person)
- [ ] Have tracking method (certified mail or upload confirmation)
- [ ] Wrote down confirmation/claim number
**You've got this, Fred. One step at a time.** 💪
---
**Document Status:**
- Started: ___/___/___
- Last updated: ___/___/___
- Submitted to VA: ___/___/___

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# Kobe VA Dependent Benefits: Lay Statement Template
**Purpose:** Document Kobe's functional limitations in your own words as his parent. This is YOUR story of what daily life is like. VA wants to hear from family members, not just doctors.
---
## Lay Statement Guide
**What is a Lay Statement?**
- First-person account from someone who witnesses the disability daily
- Describes functional impact in real-world terms
- Provides context medical records can't capture
- Shows progression over time
- Documents how disability affects family
**Why it Matters:**
- Medical records show diagnoses; lay statements show **impact**
- VA rates disability based on functional limitations, not just diagnosis
- Your observations carry significant weight
- Fills gaps between doctor visits
**Key Principles:**
1. **Be specific** - "can't tie shoes" not "has motor problems"
2. **Use examples** - Real incidents, not generalizations
3. **Be honest** - Don't exaggerate, but don't minimize
4. **Compare to peers** - "Other 10-year-olds can do X, Kobe cannot"
5. **Show permanence** - "Has been this way since age X"
6. **Document progression** - Better, worse, or stable over time
---
## Template: Lay Statement for Kobe's VA Dependent Benefits Claim
**SWORN STATEMENT IN SUPPORT OF CLAIM FOR VA DEPENDENT BENEFITS**
**Claimant:** [Kobe's Full Legal Name]
**Date of Birth:** [MM/DD/YYYY]
**Relationship:** Frederick Book, Father
**Date:** [Today's Date]
---
### SECTION 1: INTRODUCTION & BACKGROUND
**My name is Frederick Book, and I am the father of [Kobe's Full Name], born [date]. I have been [Kobe's] primary caregiver since birth and have witnessed his developmental challenges firsthand every day.**
**I am writing this statement to describe [Kobe's] functional limitations and how his disability affects his daily life. This statement is based on my direct personal observations as his parent.**
**Background:**
- I first noticed [Kobe] was different from other children when he was approximately [age/timeframe]
- The first signs were [describe early concerns - speech delays, motor delays, behavioral issues, etc.]
- We sought medical evaluation around [date/age], which resulted in diagnoses of [list conditions]
- [Kobe] has been receiving [therapies/services] since [age/year]
---
### SECTION 2: ACTIVITIES OF DAILY LIVING (ADLs)
**The VA evaluates functional capacity across multiple life domains. Describe Kobe's abilities in each area:**
#### A. Personal Hygiene & Self-Care
**Bathing:**
- [ ] Requires complete assistance
- [ ] Requires partial assistance (describe what help is needed)
- [ ] Can bathe independently but needs reminders/supervision
- [ ] Cannot safely adjust water temperature
- [ ] Needs help washing certain body parts
- [ ] Other: _______________________
**Example narrative:**
"[Kobe] cannot bathe himself independently. At age [X], he still requires me to run the bath, test water temperature, hand him soap, and remind him to wash each body part. If left alone, he will sit in the water for 30+ minutes without washing. He does not understand the sequence of steps needed to complete bathing."
**Toileting:**
- [ ] Fully toilet trained, no issues
- [ ] Requires reminders to use bathroom
- [ ] Has frequent accidents (describe frequency)
- [ ] Needs help with hygiene after toileting
- [ ] Cannot wipe properly
- [ ] Nighttime bedwetting (frequency: _____)
- [ ] Other: _______________________
**Example narrative:**
"[Kobe] struggles with toileting independence. He has accidents [X] times per week because he does not recognize the urge to go or waits too long. He requires reminders every 2-3 hours. He cannot properly wipe himself and needs assistance with hygiene to prevent rashes and infections."
**Dressing:**
- [ ] Cannot dress independently
- [ ] Can dress but chooses inappropriate clothing for weather
- [ ] Cannot manage buttons, zippers, or laces
- [ ] Puts clothes on backwards/inside-out
- [ ] Needs verbal prompting through each step
- [ ] Other: _______________________
**Example narrative:**
"At age [X], [Kobe] cannot dress himself without step-by-step verbal guidance. He cannot tie shoes, button shirts, or zip jackets. He will wear shorts in winter or heavy sweatshirts in summer if not directed. He does not understand that underwear goes on first or that shirts have a front and back."
**Grooming:**
- [ ] Cannot brush teeth without assistance
- [ ] Does not recognize when grooming is needed
- [ ] Cannot comb/brush hair
- [ ] Does not understand nail trimming is needed
- [ ] Resists grooming activities
- [ ] Other: _______________________
**Example narrative:**
"[Kobe] will not brush his teeth unless I physically hand him the toothbrush with toothpaste already on it and stand next to him providing verbal prompts. Even then, he brushes for only 5-10 seconds unless I tell him to continue. He does not recognize when his hair is messy or his hands are dirty."
---
#### B. Eating & Nutrition
**Meal Preparation:**
- [ ] Cannot prepare any food independently
- [ ] Can only prepare very simple foods (toast, cereal)
- [ ] Cannot safely use stove or sharp objects
- [ ] Does not recognize when food is spoiled
- [ ] Cannot follow recipe or multi-step directions
- [ ] Other: _______________________
**Example narrative:**
"[Kobe] cannot prepare food beyond opening pre-packaged snacks. He cannot safely use the stove, oven, or sharp knives. He does not understand cooking sequences or food safety. If told to make lunch, he might eat cereal dry from the box or attempt to eat frozen food without heating it."
**Eating Behavior:**
- [ ] Eats appropriately without issues
- [ ] Eats too fast and chokes easily
- [ ] Extremely picky eater (limited food tolerance)
- [ ] Does not recognize when full (overeats)
- [ ] Does not recognize hunger (undereats)
- [ ] Messy eating, poor utensil use
- [ ] Other: _______________________
**Example narrative:**
"[Kobe] has significant eating challenges. He will eat only [list limited foods] and refuses to try new foods. He does not recognize hunger cues and will not eat unless reminded. He eats very quickly and has choked on multiple occasions, requiring supervision during meals."
---
#### C. Communication & Social Function
**Speech & Language:**
- [ ] Non-verbal or minimally verbal
- [ ] Limited vocabulary for age
- [ ] Cannot hold conversation
- [ ] Echolalia (repeats phrases without understanding)
- [ ] Cannot express needs clearly
- [ ] Cannot answer simple questions
- [ ] Other: _______________________
**Example narrative:**
"[Kobe's] speech is significantly delayed. At age [X], his vocabulary is equivalent to a [younger age]-year-old. He cannot hold a back-and-forth conversation, answer open-ended questions, or explain what happened at school. When upset or hurt, he cannot tell me what's wrong. He repeats phrases from TV shows instead of forming original sentences."
**Social Interaction:**
- [ ] Does not interact with peers
- [ ] Prefers to play alone
- [ ] Does not understand social cues
- [ ] Cannot make or keep friends
- [ ] Inappropriate social behavior
- [ ] Does not respond to name
- [ ] No eye contact
- [ ] Other: _______________________
**Example narrative:**
"[Kobe] does not have friends and does not seek out other children. At the playground, he plays alone while children his age play together. He does not understand turn-taking, sharing, or cooperative play. Other children have stopped inviting him to birthday parties because he does not engage appropriately."
**Understanding & Following Directions:**
- [ ] Cannot follow simple one-step directions
- [ ] Can follow one-step but not multi-step directions
- [ ] Requires visual cues in addition to verbal
- [ ] Forgets directions immediately after given
- [ ] Cannot generalize instructions to new situations
- [ ] Other: _______________________
**Example narrative:**
"[Kobe] can follow only very simple, one-step directions like 'sit down' or 'come here.' If I give a two-step direction like 'go upstairs and get your shoes,' he will forget the second part before reaching the stairs. He cannot follow classroom instructions that other children understand easily."
---
#### D. Safety & Judgment
**Safety Awareness:**
- [ ] No sense of danger
- [ ] Wanders or elopes
- [ ] Touches hot stoves, electrical outlets
- [ ] Runs into street without looking
- [ ] Talks to strangers inappropriately
- [ ] Cannot be left alone for any length of time
- [ ] Other: _______________________
**Example narrative:**
"[Kobe] has no safety awareness. He will run into the street after a ball without looking for cars. He touches hot stoves even after being burned before. He does not recognize that strangers can be dangerous and would go with anyone who offered him candy. I cannot leave him alone in the house even for 5 minutes."
**Supervision Required:**
- [ ] Requires 24/7 direct supervision
- [ ] Can be left alone for short periods (< 15 minutes)
- [ ] Can be left alone but needs check-ins
- [ ] Cannot be left overnight
- [ ] Requires supervision for specific activities (list: _______)
- [ ] Other: _______________________
**Example narrative:**
"[Kobe] requires constant direct supervision. I cannot shower without bringing him into the bathroom because he will get into something dangerous or hurt himself. I cannot sleep through the night because he wakes and wanders, potentially leaving the house. He has tried to climb out windows, turn on the stove, and leave the house in the middle of the night."
---
#### E. Learning & School
**Educational Setting:**
- [ ] Attends special education full-time
- [ ] Attends general education with aide
- [ ] Cannot attend traditional school (homeschooled/alternative)
- [ ] Has IEP (Individualized Education Plan)
- [ ] Has 504 plan
- [ ] Requires 1:1 aide
- [ ] Other: _______________________
**Academic Function:**
- [ ] Reading level: [grade equivalent vs. actual grade]
- [ ] Math level: [grade equivalent vs. actual grade]
- [ ] Cannot complete homework independently
- [ ] Does not retain information
- [ ] Cannot take tests without modifications
- [ ] Other: _______________________
**Example narrative:**
"[Kobe] is in [grade] but functions academically at a [lower grade] level. He has an IEP and receives special education services for [hours/subjects]. He requires a 1:1 aide to stay on task and complete assignments. Without constant redirection, he will sit and do nothing or engage in disruptive behavior. He cannot complete homework without me sitting next to him providing step-by-step guidance."
**Behavioral Issues at School:**
- [ ] Frequent meltdowns/tantrums
- [ ] Aggressive toward peers or staff
- [ ] Self-injurious behavior
- [ ] Elopement (runs away from class)
- [ ] Cannot sit still/constant movement
- [ ] Disrupts class
- [ ] Other: _______________________
**Example narrative:**
"[Kobe's] school has called me [X] times this year due to behavioral incidents. He has meltdowns when frustrated, hitting himself or throwing materials. He cannot sit in circle time without running around the room. He has been sent home early on [number] occasions because staff could not manage his behavior safely."
---
#### F. Behavioral & Emotional Regulation
**Emotional Control:**
- [ ] Frequent meltdowns (describe frequency and triggers)
- [ ] Cannot calm self down
- [ ] Cries for hours over minor issues
- [ ] Rages and destroys property
- [ ] Self-injurious behavior (hits self, bangs head)
- [ ] No emotional regulation
- [ ] Other: _______________________
**Example narrative:**
"[Kobe] has severe emotional regulation problems. He has meltdowns [X] times per week, triggered by [common triggers: transitions, denied requests, sensory input]. During meltdowns, he [describe: screams, hits himself, throws objects, etc.]. These can last 30 minutes to 2 hours. He cannot be reasoned with or calmed. I have to ensure the environment is safe and wait for the storm to pass."
**Sleep Issues:**
- [ ] Cannot fall asleep independently
- [ ] Wakes frequently during night
- [ ] Requires co-sleeping for safety
- [ ] Night terrors or nightmares
- [ ] Sleeps only [X] hours per night
- [ ] Irregular sleep schedule
- [ ] Other: _______________________
**Example narrative:**
"[Kobe] has severe sleep disturbances. He cannot fall asleep without me lying next to him, which can take 1-3 hours. He wakes 3-5 times per night and cannot self-soothe back to sleep. He averages [X] hours of sleep per night, far below what is healthy for his age. This affects his behavior and learning the next day."
**Repetitive Behaviors:**
- [ ] Stimming (describe: hand flapping, rocking, etc.)
- [ ] Obsessive interests
- [ ] Rigid routines (meltdowns if disrupted)
- [ ] Repetitive questions or phrases
- [ ] Other: _______________________
**Example narrative:**
"[Kobe] has rigid routines and becomes extremely distressed by changes. He asks the same question 50+ times per day even after being answered. He lines up toys compulsively and has a meltdown if anyone moves them. He flaps his hands and rocks when excited or anxious. These behaviors interfere with his ability to participate in normal activities."
---
### SECTION 3: COMPARISON TO PEERS
**What children [Kobe's] age typically can do that he cannot:**
**At age [X], most children can:**
1. [Dress themselves completely] - Kobe cannot
2. [Tie their own shoes] - Kobe cannot
3. [Make simple meals like sandwiches] - Kobe cannot
4. [Bathe independently] - Kobe cannot
5. [Play cooperatively with friends] - Kobe cannot
6. [Read at grade level] - Kobe reads at [lower] level
7. [Follow multi-step directions] - Kobe can only follow one-step
8. [Be left alone for short periods] - Kobe cannot be left alone at all
9. [Complete homework independently] - Kobe requires constant help
10. [Recognize danger] - Kobe has no safety awareness
**These gaps have existed since early childhood and show no signs of improvement despite years of therapy and intervention.**
---
### SECTION 4: IMPACT ON FAMILY
**How [Kobe's] disability affects our family:**
"Caring for [Kobe] is a full-time job that affects every aspect of our lives:
**Employment Impact:**
- I [cannot work / work limited hours / had to quit job / etc.] due to his care needs
- He cannot attend after-school programs, limiting my work availability
- Frequent school calls require me to leave work
- [Spouse/other parent] impact: [describe]
**Financial Impact:**
- Medical expenses: [therapies, medications, equipment]
- Special education tutoring: $___/month
- Respite care when available: $___/hour
- Lost income due to caregiving: $___/year
- Cannot afford [specific needs] due to cost
**Sibling Impact:**
- His siblings receive less attention due to his high needs
- [Describe specific impacts on siblings]
- Family activities are limited by what he can handle
**Social Isolation:**
- We cannot attend family gatherings because of his behavioral needs
- We have no social life due to lack of respite care
- Friends have stopped inviting us places
- We cannot take normal family vacations
**Physical & Emotional Toll:**
- I am exhausted from 24/7 caregiving
- Chronic stress from constant vigilance
- Grief over the childhood experiences he cannot have
- Worry about his future when I'm no longer able to care for him
**This is not a temporary situation. [Kobe's] disabilities are permanent and will require lifelong care and support.**"
---
### SECTION 5: PROGNOSIS & FUTURE
**What the future looks like:**
"Despite years of intensive therapy and intervention, [Kobe] has made minimal progress in functional skills. His doctors have indicated that his disabilities are permanent and he will require lifelong support.
**Current prognosis:**
- Will not be able to live independently as an adult
- Will not be able to maintain competitive employment
- Will require supervised living arrangements
- Will need assistance with all activities of daily living
- Will require management of his care indefinitely
**We have tried:**
- [List therapies: speech, occupational, behavioral, etc.]
- [Medications if applicable]
- [Educational interventions]
- [Behavioral plans]
**While these help manage some symptoms, they have not resulted in functional independence. The gap between [Kobe] and his peers continues to widen as he gets older.**"
---
### SECTION 6: SPECIFIC INCIDENTS & EXAMPLES
**Provide 3-5 specific recent examples that illustrate his functional limitations:**
**Example 1: [Safety Issue]**
"On [date], [Kobe] ran into the street chasing a ball without looking. A car had to slam on brakes to avoid hitting him. When I asked why he ran into the street, he said he wanted the ball. He could not understand that cars could hurt him, even though we've had this conversation hundreds of times."
**Example 2: [Self-Care Issue]**
"Last week, [Kobe] wet himself at school because he didn't go to the bathroom during designated breaks. The teacher said he was engrossed in an activity and refused to go when asked. This happens 2-3 times per month despite being age [X]."
**Example 3: [Social Issue]**
"At a birthday party on [date], [Kobe] sat in the corner lining up toy cars while the other children played games together. When the birthday boy tried to include him, [Kobe] screamed and pushed him away. We had to leave early. This is why he no longer gets invited to parties."
**Example 4: [Behavioral Issue]**
"Two days ago, I told [Kobe] we would go to the park after lunch. When lunch took longer than expected and we left 15 minutes later than planned, he had a complete meltdown. He screamed, threw his plate, hit himself in the head, and cried for 45 minutes. I could not console or reason with him."
**Example 5: [Learning Issue]**
"[Kobe's] teacher sent home a math worksheet with 10 simple addition problems (1+1, 2+2, etc.). It took us 2 hours to complete because he could not focus, could not remember what + means even after reviewing it, and kept getting up to wander around. His classmates completed the same worksheet in 15 minutes at school."
---
### SECTION 7: SUPPORTING DOCUMENTATION
**This statement is supported by:**
- [ ] Medical records from [list providers]
- [ ] IEP and school evaluations
- [ ] Psychological and developmental assessments
- [ ] Therapy records (speech, OT, behavioral)
- [ ] Statements from teachers and therapists
- [ ] [Other supporting evidence]
**I am available to provide additional information or clarification if needed.**
---
### CERTIFICATION
**I certify that the statements made in this document are true and accurate to the best of my knowledge and belief.**
**Signature:** _________________________________
**Printed Name:** Frederick Book
**Relationship to Claimant:** Father
**Date:** _____________________
**Contact Information:**
Address: [Your Address]
Phone: [Your Number]
Email: [Your Email]
---
## IMPORTANT TIPS FOR COMPLETING THIS STATEMENT
**Dos:**
✅ Be specific and give examples
✅ Use your own words (don't copy medical terminology)
✅ Describe what you personally witness
✅ Compare to typical children the same age
✅ Explain how long issues have existed
✅ Document progression (or lack thereof)
✅ Include emotional/family impact
✅ Sign and date
**Don'ts:**
❌ Exaggerate or lie
❌ Use vague terms like "he has problems"
❌ Just list diagnoses without describing impact
❌ Focus only on what he CAN do
❌ Minimize the challenges
❌ Leave out embarrassing or difficult details
❌ Forget to include specific examples
**Remember:**
- This is YOUR voice as his parent who sees him daily
- Medical records show diagnoses; your statement shows impact
- VA needs to understand what his daily life is actually like
- Be honest, be thorough, be specific
- This statement carries significant weight in the claim
---
**Questions to ask yourself as you write:**
- Would VA understand what a typical day looks like for him?
- Have I shown WHY this is disabling, not just THAT he has a diagnosis?
- Have I compared him to kids his age?
- Have I explained how long this has been going on?
- Have I shown that it's permanent, not temporary?
- Have I documented the impact on the whole family?
**Your statement, combined with medical records, paints a complete picture for VA.**

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# Template Letter: Requesting Childhood Medical Records for Kobe
**Purpose:** Request medical records from childhood providers to document developmental delays, diagnoses, and functional limitations for VA dependent benefits claim.
---
## Template for Pediatrician / Primary Care Provider
**[Date]**
**[Provider Name / Medical Records Department]**
**[Clinic/Hospital Name]**
**[Address]**
**[City, State ZIP]**
**Re: Medical Records Request for [Kobe's Full Legal Name]**
**Date of Birth:** [MM/DD/YYYY]
**Patient ID / Account #:** [if known]
Dear Medical Records Department,
I am requesting a complete copy of medical records for my son, **[Kobe's Full Legal Name]**, who was a patient at your facility from approximately **[start year]** to **[end year]**.
### Purpose of Request
These records are needed to support a **VA dependent benefits claim** for my son, who has a permanent disability. The Department of Veterans Affairs requires documentation of:
- Developmental delays and milestones
- Diagnoses and treatment history
- Functional limitations and impairments
- Educational accommodations and services
### Records Requested
Please provide **all available records** including:
**Clinical Documentation:**
- [ ] Complete medical history and physical exams
- [ ] Well-child visit notes (all ages)
- [ ] Sick visit notes and acute care records
- [ ] Growth charts and developmental screening results
- [ ] Immunization records
**Diagnostic Records:**
- [ ] Psychological evaluations
- [ ] Developmental assessments
- [ ] Speech/language evaluations
- [ ] Occupational therapy evaluations
- [ ] Any IQ testing or cognitive assessments
- [ ] Lab results and diagnostic test reports
**Specialist Referrals:**
- [ ] Referral letters to specialists
- [ ] Specialist consultation notes
- [ ] Treatment recommendations
- [ ] Follow-up documentation
**Educational/Developmental:**
- [ ] School health records (if maintained by your office)
- [ ] Letters documenting need for special education
- [ ] Documentation of developmental delays
- [ ] Functional limitation assessments
**Medication History:**
- [ ] Prescription records
- [ ] Medication management notes
- [ ] Response to treatment documentation
### Specific Timeframes of Interest
**Early Childhood (Birth - Age 5):**
Documentation of when delays were first noticed, early intervention services, developmental milestone tracking.
**School Age (Age 5 - Present):**
Ongoing treatment, educational impact, functional limitations, progression of condition.
### Preferred Format
- [ ] **Electronic records** (PDF via secure email to: [your email])
- [ ] **Paper copies** (mailed to address below)
- [ ] **CD/USB** (mailed to address below)
### Authorization and Release
**Patient Information:**
- Full Name: [Kobe's Full Legal Name]
- Date of Birth: [MM/DD/YYYY]
- Social Security Number: [XXX-XX-XXXX] (optional, for identification)
- Address: [Kobe's current address]
**Requesting Party:**
- Name: [Your Full Name]
- Relationship: Father / Legal Guardian
- Phone: [Your Phone Number]
- Email: [Your Email]
- Address: [Your Mailing Address]
**Purpose:** VA Dependent Benefits Claim Documentation
**I authorize the release of the above medical records to:**
- Frederick Book (parent/legal guardian)
- AND/OR directly to: Department of Veterans Affairs
**Signature:** ________________________________
**Printed Name:** [Your Full Name]
**Date:** _______________
**Notarization:** *(if required - check with provider)*
---
### Delivery Address
**Mail records to:**
Frederick Book
[Your Street Address]
[City, State ZIP]
**Questions? Contact me at:**
Phone: [Your Number]
Email: [Your Email]
---
## Additional Notes
**Timeline:**
- Allow 30-45 days for processing (HIPAA allows up to 30 days, but extensions are common)
- If records are urgent, note "TIME-SENSITIVE: VA CLAIM DEADLINE [date]"
**Fees:**
- Most providers charge per-page copying fees (typically $0.50-1.00/page)
- Some charge administrative fees ($25-50)
- Ask about fee waiver for VA benefits purposes
- Some states limit medical record fees - check Illinois law
**Follow-Up:**
- Call 10-14 days after mailing to confirm receipt
- Get name of person handling request
- Ask for estimated completion date
- Keep copy of request letter for your records
**If Provider No Longer Exists:**
- Check with state medical board for record custodian
- Contact hospital system if practice was acquired
- Try state health department archives
---
## Providers to Contact
**Create a tracking list:**
| Provider Name | Dates Seen | Request Sent | Follow-Up | Received |
|---------------|------------|--------------|-----------|----------|
| [Pediatrician Name] | [Years] | [ ] ___/___/___ | [ ] ___/___/___ | [ ] ___/___/___ |
| [Specialist Name] | [Years] | [ ] ___/___/___ | [ ] ___/___/___ | [ ] ___/___/___ |
| [Hospital/Clinic] | [Years] | [ ] ___/___/___ | [ ] ___/___/___ | [ ] ___/___/___ |
---
## Key Points to Emphasize
**What VA Needs to See:**
1. **When** the disability began (early childhood preferred)
2. **What** the diagnoses are (formal, from medical professionals)
3. **How** it affects daily function (ADLs, learning, social skills)
4. **Progression** over time (stable vs. worsening)
5. **Treatment history** (medications, therapies, interventions)
**Timeline is Critical:**
- VA wants to see the disability existed **before age 18** (or before age 23 if in school)
- Earlier documentation = stronger claim
- Continuous treatment history shows permanence
**What Makes Records Valuable:**
- Specific diagnoses with DSM/ICD codes
- Functional assessments (what child can/can't do)
- Developmental milestone delays documented
- Need for special education services
- Comparison to age-appropriate norms
- Provider statements about permanence/prognosis
---
## Sample Follow-Up Phone Script
**When calling to check status:**
"Hi, I'm calling to follow up on a medical records request I sent on [date] for my son [Kobe's name], date of birth [DOB].
The request is for VA dependent benefits documentation, so it's fairly time-sensitive.
Can you tell me:
1. Have you received my request?
2. What's the estimated completion date?
3. Is there anything else you need from me?
4. What will the cost be?
Thank you!"
---
## If Records Are Incomplete
**What to do if provider says "we don't have that":**
1. **Ask specifically** what they DO have
2. **Request index/summary** of available records
3. **Ask about storage/archive** - older records may be off-site
4. **Get statement** documenting what's missing (helps explain gaps to VA)
**Sample request:**
"If you don't have the complete records, could you please provide:
- A summary of what you DO have
- Dates of service you can verify
- A statement documenting that records prior to [year] are no longer available
This will help explain the gap in documentation to the VA."
---
## Privacy Tip
**HIPAA Right of Access:**
- You have absolute right to your child's medical records
- Providers MUST provide them (with limited exceptions)
- 30-day response time is federal law
- If denied, ask for written explanation and escalate to state health department
---
**This template is ready to customize and send. Fill in the bracketed fields and mail certified mail (return receipt requested) to create paper trail.**
**Track everything - VA claims live and die by documentation!**