VA Form 20-0996

INSTRUCTIONS FOR COMPLETING DECISION REVIEW REQUEST: HIGHER-LEVEL REVIEW

IMPORTANT: Please read the instructions carefully to help you complete this form. Some parts of this form contain notes or specific instructions for completing that section. Filling out this form completely and accurately will decrease the amount of time it takes to process your Higher-Level Review request.

USE THIS FORM TO REQUEST A HIGHER-LEVEL REVIEW OF A 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. This form must be received by VA WITHIN ONE YEAR OF THE DATE VA PROVIDED NOTICE OF OUR DECISION.

What to know about the Higher-Level Review:

The Higher-Level Reviewer will not consider any evidence received after the notification date of the prior decision.
A Higher-Level Review may not be requested for the review of a Higher-Level Review decision or a Board of Veterans' Appeals 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 www.va.gov/decision-reviews/.

You may contact your accredited representative (attorney, claims agent or Veterans Service Organization (VSO)) to assist you. If you have not already selected a representative or if you want to change your representative, a searchable database of VA-recognized VSOs, VSO representatives, VA-accredited attorneys and claims agents is available at www.va.gov/ogc/apps/accreditation/index.asp. You can also ask VA to help you by contacting us at 1-800-827-1000.

Submit your request for Higher-Level Review to the local VA office or processing center identified on your decision notification letter. It is important to keep a copy of all completed forms and materials you give to VA. You can find mailing address information at www.va.gov/decision-reviews/higher-level-review/.

You may request to have your Higher-Level Review conducted at either the same or a different office within the agency of original 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 and therefore can only be reviewed at a specific office.

For information on Veterans Health Administration (VHA) health care services, visit www.va.gov/health-care/about-va-health-benefits. To learn more about VHA health care services available related to military sexual trauma (MST), you can contact a VHA MST Coordinator. A list is available at www.mentalhealth.va.gov/msthome/vha-mst-coordinators.asp or you can contact your local VA medical facility and ask to speak to a MST Coordinator.

SPECIFIC INSTRUCTIONS FOR DECISION REVIEW REQUEST: HIGHER-LEVEL REVIEW

Section I - Veteran's Identification Information

Provide all available information to identify the veteran in Section I. VA must have enough information to be able to identify the veteran. VA may return the form if the form is incomplete.

If you are experiencing homelessness, or are at risk of experiencing homelessness, mark the check box at the bottom of Item 6. If you wish to request priority processing for other reasons, you may file VA Form 20-10207, Priority Processing Request, with this form.

Section II - Claimant's Identification Information (If other than veteran)

If the claimant is different than the veteran, fill out the information in Section II. Without this information, we will be unable to identify the claimant.

If you are a healthcare provider (or an agent or employee of a healthcare provider) requesting review of a VA payment decision, you must indicate the healthcare provider as the claimant and complete all relevant information in the claimant identification section.

SPECIFIC INSTRUCTIONS FOR DECISION REVIEW REQUEST: HIGHER-LEVEL REVIEW (Continued)

Section III - Benefit Type

This form may only be submitted for review of an issue(s) related to one benefit type: Compensation, Pension/DIC/Survivors Benefits, Fiduciary, Life Insurance, Education, Loan Guaranty, Veteran Readiness and Employment, Veterans Health Administration, or National Cemetery Administration. If you would like to file for multiple benefit types (e.g., Compensation and Life Insurance), you must complete a separate Higher-Level Review request form for each benefit type. If your disagreement is with a decision by the Veterans Health Administration, even if you are seeking reimbursement for medical expenses or non-VA emergency care, you must select Veterans Health Administration in Item 15.

Section IV - Optional Informal Conference

You or your appointed representative may request an informal conference to identify errors of fact or law in the decision under review with the Higher-Level Reviewer assigned to complete the review of your issue(s) by marking the check box in Item 16A. Evidence that was not of record at the time VA issued notice of the decision will not be considered. Requesting an informal conference may delay issuance of a Higher-Level Review decision.

To avoid potential delays, you may submit a written statement instead of requesting an informal conference. This statement should include your argument highlighting VA's potential misreading of facts, or its potential misapplication of law to the facts that the evidentiary record has already established.

VA will make two attempts to contact you or your representative to schedule your informal conference. If you would like VA to contact your representative instead of you, you must include the representative's name and contact information in Items 17A and 17B. In order for VA to speak to your representative on your behalf, a valid VA Form 21-22a, Appointment of Individual as Claimant's Representative or VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative must be of record or included with this application. If VA is unable to reach you or your representative after two attempts, the Higher-Level Reviewer will move forward with completing your Higher-Level Review request and issue a decision.

Section V - Issues for Higher-Level Review

In Item 18A, you should identify each issue decided by VA which you would like included in your Higher-Level Review. Please refer to your VA decision notification letter(s) for issues previously decided by VA.

In Item 18B, you should enter the date of VA's decision for each issue. Only the issue(s) you list on this form will be addressed during the Higher-Level Review.

To opt into the modernized review system from the legacy appeals system, you must submit this form within 60 days from the date of the Statement of the Case or Supplemental Statement of the Case and list the issue(s) which you are seeking review in Item 18A. The issues listed in 18A will be withdrawn from the legacy appeals system and addressed in the modernized review system as a Higher-Level Review. You cannot return to the legacy system for any issue(s) you withdraw.

Section VI - Certification and Signature

Please be sure to sign your request for Higher-Level Review. It is recommended that you do not sign in pencil, as forms signed in pencil may be returned. For alternate signer certification, please include VA Form 21-0972, Alternate Signer Certification.

Section VII - Authorized Representative Signature

A VA authorized representative may sign this section in lieu of the veteran or claimant signature in section VII, as long as a valid VA Form 21-22 or VA Form 21-22a is of record or included with this application.

SECTION IV - OPTIONAL INFORMAL CONFERENCE

16. YOU OR YOUR AUTHORIZED REPRESENTATIVE MAY REQUEST AN INFORMAL CONFERENCE. (VA will only conduct one informal conference associated with this request for Higher-Level Review.)

16A.

16A. I WOULD LIKE AN OPTIONAL INFORMAL CONFERENCE. I understand I will not be able to discuss or introduce new evidence that was not part of my file at the time of the decision at issue, and that VA may be able to make a decision faster if I do not request an informal conference. By requesting an informal conference, I understand VA may contact me or my representative in an available manner, such as mail, telephone, electronic notice, or by other means to schedule my conference.

16B. IF YOU SELECTED THE BOX ABOVE, VA will make two attempts to contact you OR your representative to schedule the informal conference. INDICATE ONE PREFERENCE BY CHECKING THE APPROPRIATE BOX:

16B. 1

Contact the veteran/claimant. If contact will be by phone, contact in the morning hours based on time zone.

16B. 2

Contact the veteran/claimant. If contact will be by phone, contact in the afternoon hours based on time zone.

16B. 3

Contact the representative. If contact will be by phone, contact in the morning hours based on time zone.

16B. 4

Contact the representative. If contact will be by phone, contact in the afternoon hours based on time zone.

17. IF YOU WOULD LIKE VA TO CONTACT YOUR REPRESENTATIVE, YOU MUST PROVIDE YOUR REPRESENTATIVE'S CONTACT INFORMATION BELOW:

17A. REPRESENTATIVE'S NAME (First)

17A. REPRESENTATIVE'S NAME (Last)

17B. REPRESENTATIVE'S TELEPHONE NUMBER (Include Area Code)

17C. REPRESENTATIVE'S E-MAIL ADDRESS

SECTION V - ISSUES FOR HIGHER-LEVEL REVIEW

18. If you are responding to a Statement of the Case (SOC) or a Supplemental Statement of the Case (SSOC): By submitting this form, you are withdrawing the eligible legacy appeal issue(s) listed in 18A in their entirety, and any associated hearing requests, and opting for the issues to be decided in the modernized review system. You acknowledge you cannot return to the legacy appeals system for the issue(s) withdrawn.

IDENTIFY IN ITEM 18A EACH ISSUE DECIDED BY VA FOR WHICH YOU ARE REQUESTING A HIGHER-LEVEL REVIEW. Refer to your decision notification letter(s) for your issue(s) VA has previously decided. For each issue, identify the date of VA's most recent decision on the issue in Item 18B. If the space below is insufficient to include the information regarding your issue(s), it is acceptable to indicate that in the space below and attach additional pages to this form to complete your request. Include your name and file number on each page attached.

IMPORTANT: You may only list issues for the benefit type selected in Item 15, Section III.

18A. SPECIFIC ISSUE(S) OF DISAGREEMENT (REQUIRED)

18B. DATE OF VA DECISION NOTIFICATION LETTER (REQUIRED)

18A. 1

18B. 1

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18B. 4

18A. 5

18B. 5

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18B. 7

SECTION V - ISSUES FOR HIGHER-LEVEL REVIEW (Continued)

18A. SPECIFIC ISSUE(S) OF DISAGREEMENT (REQUIRED)

18B. DATE OF VA DECISION NOTIFICATION LETTER (REQUIRED)

18A. 8

18B. 8

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SECTION VI - CERTIFICATION AND SIGNATURE

NOTE: This section is MANDATORY and completion is required to process your claim unless accompanied by VA Form 21-0972, Alternate Signer Certification or Section VII is completed.

I CERTIFY that the statements on this form are true and correct to the best of my knowledge and belief.

19A. SIGNATURE OF VETERAN OR CLAIMANT

19B. DATE SIGNED (MM/DD/YYYY)

SECTION VII - AUTHORIZED REPRESENTATIVE SIGNATURE

I CERTIFY that the statements on this form are true and correct to the best of my knowledge and belief.

NOTE: A representative'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 representative is of record with VA or included with this application.

20A. NAME OF VA AUTHORIZED REPRESENTATIVE (First)

20A. NAME OF VA AUTHORIZED REPRESENTATIVE (Last)

20B. SIGNATURE OF VA AUTHORIZED REPRESENTATIVE

20C. DATE SIGNED (MM/DD/YYYY)

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.

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 VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Veteran Readiness and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary.

RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control Number. The OMB control number for this project is 2900-0862, and it expires 03/31/2027. Public reporting burden for this collection of information is estimated to average 15 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden to VA Reports Clearance Officer at VACOPaperworkReduAct@VA.gov. Please refer to OMB Control No. 2900-0862 in any correspondence. Do not send your completed VA Form 20-0996 to this email address.

			VA DATE STAMP (DO NOT WRITE IN THIS SPACE)
DECISION REVIEW REQUEST: HIGHER-LEVEL REVIEW
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 5. Use this form to request a Higher-Level Review of a decision you received. A Higher-Level Review is a new review of an issue(s) previously decided by VA based on the evidence of record at the time of the prior decision. For more information call us toll-free at 1-800-827-1000 (TTY: 711) or contact us online through ASK VA: https://ask.va.gov/. VA forms are available at https://www.va.gov/find-forms/.

INSTRUCTIONS FOR COMPLETING DECISION REVIEW REQUEST: HIGHER-LEVEL REVIEW

SPECIFIC INSTRUCTIONS FOR DECISION REVIEW REQUEST: HIGHER-LEVEL REVIEW

SPECIFIC INSTRUCTIONS FOR DECISION REVIEW REQUEST: HIGHER-LEVEL REVIEW (Continued)

DECISION REVIEW REQUEST: HIGHER-LEVEL REVIEW