DMS Nexus Letter Intake Form

This form provides our physician with some background information needed for reviewing your case. Please answer all questions as accurately as possible, but perfect wording is not required.

Please note that a nexus letter is a medical opinion, not a guarantee of VA benefits approval, and is based solely on medical evidence and accepted medical standards.

Who is completing this form?* This field is required.

Veteran

Legal representative/attorney

Other

Veteran’s Full Legal Name* This field is required.

First Name

Last Name

Veteran’s Date of Birth* This field is required.

Date

Veteran’s Email Address * This field is required.

example@example.com

Veteran’s Phone Number* This field is required.

Please enter a valid phone number.

Veteran’s State of Residence* This field is required.

Branch of Service * This field is required.Select the branch of service relevant to your claimed condition.

Army

Navy

Air Force

Marine Corps

Coast Guard

National Guard / Reserves

Other

Date(s) of Active Duty Service* This field is required.

Military Occupational Specialty (MOS) / Rate / AFSC* This field is required.List the position relevant to your claimed condition.

Duty Stations / Ships / Units* This field is required.List all relevant to your claimed condition.

DeploymentsIf applicable.

Is this a request for a federal disability accommodation medical opinion?* This field is required.

Yes

Not sure

Is this a federal position?

Yes

Not sure

Brief description of essential job duties

Work environmentCheck all that apply

Office-based

Field-based

Remote / telework eligible

Shift work

Physically demanding

Safety-sensitive role

Other

Please explain "other" from previous question.If applicable.

What medical condition(s) cause functional limitations?

Describe the functional limitations related to these conditions.E.g., standing, walking, sitting tolerance, cognitive failure, concentration, lifting, travel, attendance

Are these limitations:

Temporary

Permanent

Episodic / variable

Not sure

Has your employer already requested a medical opinion?

YESNO

If yes, who requested it?

Disability Program Manager

Human Resources

Supervisor

Other

Are specific accommodations being requested or proposed?* This field is required.

YESNO

If yes, please list requested accommodations.E.g., telework, modified schedule, ergonomic equipment, duty modifications

Do you have any supporting documents?

Employer accommodation request

Functional Capacity Evaluation (FCE)

Prior accommodation letters

Job description

Other

Please explain "other" from previous question.If applicable.

Please acknowledge:* This field is required.

I understand this is a medical opinion regarding functional limitations and accommodations, not an employment or legal determination.

I understand accommodations are subject to employer review and approval.

What is the condition for which you are requesting a nexus letter?* This field is required.Each claimed medical condition requires an independent medical analysis, including record review, diagnostic confirmation, and research for medical literature support. For this reason, each DMS nexus letter focuses on one condition.

Claimed medical condition

Has the condition been diagnosed by a licensed medical provider?* This field is required.Check one.

Yes

Not sure

Date of diagnosis for the claimed condition

Do you require completion of a Disability Benefits Questionnaire?* This field is required.Completion of a DBQ requires selection of Premier Tier; visit nexuslettermd.com for details.

YESNO

How do you believe this condition is related to military service?* This field is required.Check all that apply.

Direct service connection

Secondary to an already service-connected condition

Aggravation of a pre-existing condition

Toxic / environmental exposure

Repetitive physical strain or occupational exposure

Other (please describe below)

In-service event(s), exposure(s), or duties you believe caused or contributed to the condition* This field is required.Details are helpful, but “perfect wording” is not necessary.

Were you exposed to any of the following during service?Check all that apply.

AFFF / firefighting foam

Asbestos

Burn pits

Chlorine

Heavy metals

Pesticides / herbicides

Radiation

Repetitive physical activities

Solvents / fuels (JP-8, benzene, etc.)

Other

Explain “Other” from prior question regarding exposureIf applicable.

Approximate duration and frequency of exposure

Medical records you plan to submitCheck all that apply.

VA medical records

Private medical records

Service Treatment Records (STRs)

C&P exam reports

Imaging / lab reports

Prior nexus letters or medical opinions

Approximate number of pages you expect to submit* This field is required.Additional fees may apply for extensive record review.

Under 25 pages

25-50 pages

More than 50 pages

Has this condition already been filed with the VA?* This field is required.Check one

Yes - pending

Yes - denied

No - not yet filed

If denied, do you know the reason for denial?Optional

Which service tier are you requesting?* This field is required.Please visit our website at nexuslettermd.com for a description of each tier.

Level 1 – Nexus Letter Only

Level 2 – Nexus Letter + Medical Records Summary

Level 3 – Nexus Letter + Records Summary + Physician Consultation

Would you like to request a specific physician for your medical opinion?Optional. Both physicians are licensed MDs experienced in preparing VA nexus letters. Final assignment is based on clinical appropriateness and availability.

No preference

Prefer a physician with occupational & environmental medicine expertise

Prefer a physician with addiction medicine expertise

I’m not sure — please assign the most appropriate physician

Do you need your nexus letter by a specific date?* This field is required.If yes, please give date in the next field.

YESNO

If you need your nexus letter by a specific date, please enter that here.

Date

Please review and acknowledge the following statements* This field is required.

I understand that a nexus letter is a medical opinion, not a guarantee of VA benefits approval.

I understand that the physician must provide an independent, evidence-based opinion, which may or may not support my claim.

I understand that payment is for medical expertise and record review, not for a specific outcome.

I understand that each medical condition requires a separate nexus analysis and may require a separate fee.

I affirm that the information provided is accurate to the best of my knowledge.

I understand that this service provides an independent medical opinion only and does not establish a physician–patient relationship or provide medical treatment.

Is there anything else you believe is important for the physician to know?Optional

Veteran/Representative Name* This field is required.

Date Submitted* This field is required.

Date

DMS Nexus Letter Intake Form