# 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.**