We request medical evidence from each medical source that the claimant identifies as having evaluated, examined, or treated him or her. For the definition of medical source, see DI 22505.001A.4.

For general instructions on requesting medical evidence, see DI 22505.006.

For a suggested model letter to use when requesting medical evidence of record in adult claims, see NL 00705.770.

Generally, medical evidence should include:

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  Medical history

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  Objective medical evidence (medical signs, laboratory findings, or both)

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  Prescribed treatment and claimant’s response to the treatment

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  Diagnosis and prognosis

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  Medical opinion

NOTE: You are not required to follow up with a medical source solely to obtain a medical opinion. For additional information about follow up requests for medical evidence, see DI 22505.035.

Generally, we request a medical opinion, along with medical evidence, through a request for medical evidence. Request a medical opinion from all of the claimant’s medical sources with the exception of the following situations or sources:

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  In statutory blindness cases.

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  From a laboratory.

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  From a medical source who previously refused to provide medical opinions for all of his or her patients.

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  From a Department of Veterans Affairs (VA) facility. (As a matter of policy, the VA does not permit its physicians and psychologists to provide this type of opinion.) For additional information, see DI 22505.022.

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  From the National Personnel Records Center. For additional information, see DI 22505.024.

Document all disability development undertaken on the case development summary worksheet. For details, see DI 20503.001E.