20-0996 Decision Review Request: Higher-level Review

INFORMATION AND INSTRUCTIONS FOR COMPLETING DECISION REVIEW REQUEST:
HIGHER-LEVEL REVIEW
IMPORTANT: Please read the information below carefully to help you complete this form quickly and accurately. Some
parts of the form also contain notes or specific instructions for completing that part.
Use this form to request a HIGHER-LEVEL REVIEW of the decision you received. A HIGHER-LEVEL REVIEW is a
new review of an issue(s) previously decided by the Department of Veterans Affairs (VA) based on the evidence of record at
the time VA issued notice of the prior decision. The higher-level reviewer WILL NOT consider any evidence received after
the notification date of the prior decision. This form must be submitted to VA within one year of the date VA provided notice
of our decision. For additional information on the HIGHER-LEVEL REVIEW process or a list of review options that allow VA
to consider new evidence and how to file, visit VA.gov/decision-reviews.
Submit your request for HIGHER-LEVEL REVIEW to the local VA office or processing center identified on your decision
notice letter. It is important that you keep a copy of all completed forms and materials you give to VA. This form has several
key components, which when filled out completely and accurately, will decrease the amount of time it takes to process your
HIGHER-LEVEL REVIEW request. This form may only be submitted for review of an issue(s) related to one benefit type
(Compensation, Pension/Survivors Benefits, Fiduciary, Insurance, Education, Loan Guaranty, Vocational Rehabilitation &
Employment, Veterans Health Administration, or National Cemetery Administration). If you would like to file for multiple
benefit types, you must complete a separate HIGHER-LEVEL REVIEW request for each benefit type.
You may contact your accredited representative (attorney, claims agent, and Veterans Service Organizations (VSOs)
representative) to assist you in completing this form. If you have not already selected a representative, or if you want to
change your representative, a searchable database of VA-recognized VSOs, VA-accredited attorneys, claims agents, and
VSO representatives is available at https://www.va.gov/ogc/apps/accreditation/index.asp. Contact your local VA office for
assistance with appointing a representative or visit www.ebenefits.va.gov.
You can also ask VA to help you fill out the application by contacting us at the number provided on your decision notification
letter or at 1-800-827-1000. Before you contact us, please make sure you gather the necessary information and materials
(decision notification letter, etc.), and complete as much of the form as you can.

SPECIFIC INSTRUCTIONS FOR DECISION REVIEW REQUEST: HIGHER-LEVEL REVIEW
Part I - Claimant's Identifying Information
Please note that it would assist VA if you provide all the personal information in Part I. However, if you provide certain
information specific to the claimant such as the claimant's last name and Social Security Number or VA file number, VA will
be able to identify the claimant in our system and would not necessarily consider this request incomplete if other information
in Part I, such as the claimant's address and telephone number, is excluded. This request form may only be completed for
review of an issue(s) related to one benefit type. Select only one benefit type in item 12. If you would like to file for
multiple benefit types, you must complete a separate HIGHER-LEVEL REVIEW request form for each benefit type.
Part II - HIGHER-LEVEL REVIEW Options
You may request to have your HIGHER-LEVEL REVIEW conducted at either the same or a different office within the
agency of jurisdiction that decided your issue(s). Please note that decisions on certain types of issues are processed at only
a single VA office or facility. Accordingly, some issues cannot be reviewed at an office other than the office that decided
your issue(s). For a list of these issue types visit VA.gov/decision-reviews. If we cannot fulfill your request, we will notify
you at the time the HIGHER-LEVEL REVIEW decision is made.
You or your appointed representative may request an informal conference with the higher-level reviewer assigned to
complete the review of your issue. The sole purpose of the optional telephone contact is to give you or your representative
the opportunity to identify any errors of fact or law in the prior decision. VA may make up to two attempts to call you at the
telephone number provided to VA to schedule your informal conference. If you would like VA to instead place the call to
schedule your informal conference to your VA authorized representative you must place the representative's name and
phone number in Box 14. If VA is unable to reach you or your representative, the higher-level reviewer will move forward
with completing your request for higher-level review and will issue a decision.
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Part III - Information to identify the issues for HIGHER-LEVEL REVIEW
The purpose of this section is for you to identify, in item 15A, each issue decided by VA that you would like as part of
your higher-level review. Please refer to your decision notification letter(s) for a list of adjudicated issues. You should
also enter the date of VA's decision for each issue, if possible. Only those issue(s) that you list on this form will be
considered for HIGHER-LEVEL REVIEW. For those issues you do not list on this form, you will still have one year from
the date of the decision notification letter to request a HIGHER-LEVEL REVIEW for those issues, or to have them
reviewed in a different lane.
Upon receipt of a Statement of the Case (SOC) or Supplemental Statement of the Case (SSOC) in the legacy appeals
system, you may elect to continue your appeal either in the legacy appeals system or in the modernized review system.
Your decision notice contains further details. If you are filing this form to opt-in to the modernized review system for any
issues decided in the SOC or SSOC, you must provide notice to VA of your decision to leave the legacy appeal process
for those issues. To do so when using this form, please check the box for “OPT-IN from SOC/SSOC” in item 15 and list
the issue(s) in the SOC or SSOC for which you are seeking review under item 15A as instructed above. Your selection
of the HIGHER-LEVEL REVIEW option does not prevent you from changing the review option (in accordance with
applicable procedures) before VA renders the higher-level review decision on an issue.
Please note that by checking the “OPT-IN from SOC/SSOC” box in item 15 you are acknowledging the following:
I elect to participate in the modernized review system. I am withdrawing all eligible appeal issues listed on this form in
their entirety, and any associated hearing requests, from the legacy appeals system to seek review of those issues in
VA's modernized review system. I understand that I cannot return to the legacy appeals process for the issue(s)
withdrawn.
Part IV - Certification and Signature
Please be sure to sign this request for HIGHER-LEVEL REVIEW, certifying that the statements on the form are true
and correct to the best of the claimant's or authorized representative's knowledge and belief.
Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal
Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United
States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in the following VA systems of records published in the Federal Register: 37VA27, VA Supervised Fiduciary/Beneficiary and General Investigative RecordsVA; 58/VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records -VA; 55VA26 Loan Guaranty Home, Condominium and Manufactured
Home Loan Applicant Records, Specially Adapted Housing Applicant Records, and Vendee Loan Applicant Records -VA; and 36VA29, Veterans and Armed Forces Personnel Programs of
Government Life Insurance -VA. Your obligation to respond is required to obtain or retain benefits. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that
your records are properly associated with your claims file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of
benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1,
1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential
(38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.
Respondent Burden: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate that
you will need an average of 15 minutes to review the instructions, find the information, and complete the form. VA cannot conduct or sponsor a collection of information unless a valid OMB
control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet
Page at www.reginfo.gov/public/do/PRAMain.

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OMB Control No. 2900-XXXX
Respondent Burden: 15 minutes
Expiration Date: XXXXXXXX
VA DATE STAMP
DO NOT WRITE IN THIS SPACE

DECISION REVIEW REQUEST: HIGHER-LEVEL REVIEW
INSTRUCTIONS: PLEASE READ THE PRIVACY ACT NOTICE AND RESPONDENT BURDEN INFORMATION
ON PAGE 1 BEFORE COMPLETING THIS FORM.

PART I - CLAIMANT'S IDENTIFYING INFORMATION
NOTE: You can either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly to expedite processing the
form.
1. VETERAN'S NAME (First, Middle Initial, Last)

4. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)

3. VA FILE NUMBER (If applicable)

2. VETERAN'S SOCIAL SECURITY NUMBER

Day

Month

5. VETERAN'S SERVICE NUMBER (If applicable)

Year

6. INSURANCE POLICY NUMBER (If applicable)

7. CLAIMANT'S NAME (First, Middle Initial, Last) (If other than veteran)

8. CLAIMANT TYPE:
VETERAN

VETERAN'S SPOUSE

VETERAN'S CHILD

OTHER (Specify)

VETERAN'S PARENT

9. CURRENT MAILING ADDRESS (Number, street or rural route, City or P.O. Box, State and ZIP Code and Country)
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code
11. E-MAIL ADDRESS (Optional)

10. TELEPHONE NUMBER (Include Area Code)

12. BENEFIT TYPE: PLEASE CHECK ONLY ONE (If you would like to file for multiple benefit types, you must complete a separate request form for each benefit type.)
COMPENSATION

PENSION/SURVIVORS BENEFITS

VOCATIONAL REHABILITATION AND EMPLOYMENT

FIDUCIARY

EDUCATION

VETERANS HEALTH ADMINISTRATION

LOAN GUARANTY

INSURANCE

NATIONAL CEMETERY ADMINISTRATION

PART II - HIGHER-LEVEL REVIEW OPTIONS
13. IF YOU WOULD LIKE THE SAME OFFICE THAT ISSUED YOUR PRIOR DECISION TO CONDUCT THE REVIEW, YOU CAN MAKE THAT REQUEST BY
CHECKING THE BOX BELOW. IF YOU DO NOT CHECK THE BOX, VA WILL TAKE THAT AS A REQUEST TO HAVE A DIFFERENT OFFICE CONDUCT THE REVIEW.
(Please note VA may be unable to grant your request.)
If available, I would like HIGHER-LEVEL REVIEW conducted at the same office within the agency of original jurisdiction.
14. IN ADDITION, YOU OR YOUR AUTHORIZED REPRESENTATIVE MAY REQUEST AN INFORMAL CONFERENCE WITH THE HIGHER-LEVEL REVIEWER. (This is a
telephonic communication with the higher level reviewer for the sole purpose of pointing out errors of fact or law in the prior decision. VA will only conduct one informal conference
associated with this request for higher-level review. Check the box below to request an informal conference.)
I, or my representative, would like an informal conference. (VA will make up to two attempts to call you between 8:00a.m. and 4:30p.m. Eastern Standard Time at the
telephone number and time period you select below to schedule your informal conference. Please select up to two time periods you are available to receive a phone call.)
8:00a.m. - 10:00a.m.

10:00a.m. - 12:30p.m.

12:30p.m. - 2:00p.m.

2:00p.m. - 4:30p.m.

If you would like for VA to contact your representative, please provide your
representative's name and telephone number where he or she can be reached
at the above checked time.

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PART III - ISSUES FOR HIGHER-LEVEL REVIEW
15. YOU MUST INDICATE BELOW EACH ISSUE DECIDED BY VA FOR WHICH YOU ARE REQUESTING A HIGHER-LEVEL REVIEW. Please refer to your decision notice(s)
for a list of adjudicated issues. for each issue, please identify the date of VA's decision. You may attach additional sheets, if necessary. Please include your name and file number on each
additional sheet.
Check this box if any issue listed below is being withdrawn from the legacy appeals process.

OPT-IN from SOC/SSOC

15A. SPECIFIC ISSUE(S)

15B. DATE OF VA DECISION NOTICE

PART IV - CERTIFICATION AND SIGNATURE
NOTE: This section is MANDATORY and completion is required to process your claim; any omission may delay claim processing time.
VA AUTHORIZED REPRESENTATIVES ONLY: I certify that the claimant has authorized the undersigned representative to file this higher-level review on behalf
of the claimant and that the claimant is aware and accepts the information provided in this document. I certify that the claimant has authorized the undersigned
representative to state that the claimant certifies the truth and completion of the information contained in this document to the best of claimant's knowledge.
NOTE: A power of attorney's (POA's) signature will not be accepted unless at the time of submission of this request a valid VA Form 21-22, Appointment of Veterans
Service Organization as Claimant's Representative, or VA Form 21-22a, Appointment of Individual As Claimant's Representative, indicating the appropriate POA is of
record with VA.
I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.
16A. SIGNATURE OF VETERAN OR CLAIMANT OR VA AUTHORIZED REPRESENTATIVE (Sign in ink)

16B. DATE SIGNED

16C. NAME OF VA AUTHORIZED REPRESENTATIVE (Please Print)

ALTERNATE SIGNER CERTIFICATION AND SIGNATURE
17. I CERTIFY THAT by signing on behalf of the claimant, that I am a court-appointed representative; OR, an attorney in fact or agent authorized to act on behalf of a claimant
under a durable power of attorney; OR, a person who is responsible for the care of the claimant, to include but not limited to a spouse or other relative; OR, a manager or
principal officer acting on behalf of an institution which is responsible for the care of an individual; AND, that the claimant is under the age of 18; OR, is mentally incompetent to
provide substantially accurate information needed to complete the form, or to certify that the statements made on the form are true and complete; OR, is physically unable to
sign this form.
I understand that I may be asked to confirm the truthfulness of the answers to the best of my knowledge under penalty of perjury. I also understand that VA may request further
documentation or evidence to verify or confirm my authorization to sign or complete an application on behalf of the claimant if necessary. Examples of evidence which VA may
request include: Social Security Number (SSN) or Taxpayer Identification Number (TIN); a certificate or order from a court with competent jurisdiction showing your authority to
act for the claimant with a judge's signature and a date/time stamp; copy of documentation showing appointment of fiduciary; durable power of attorney showing the name and
signature of the claimant and your authority as attorney in fact or agent; health care power of attorney, affidavit or notarized statement from an institution or person responsible
for the care of the claimant indicating the capacity or responsibility of care provided; or any other documentation showing such authorization.
17A. SIGNATURE OF ALTERNATE SIGNER (Sign in ink)

17B. DATE SIGNED

17C. NAME OF ALTERNATE SIGNER (Please Print)

PENALTY: The law provides severe penalties which include a fine, imprisonment, or both, for the willful submission of any statement or evidence of a material fact,
knowing it to be false.
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