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

Rank or Preferred Form of AddressOptional.

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.

For Veterans Outside the U.S. and its Territories: Provide City and Country.

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 Relevant to Your Claimed Condition.* This field is required.

Duty Stations / Ships / Units Relevant to Your Claimed Condition.* This field is required.

Deployments Relevant to Your Claimed Condition.If applicable.

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? (A DBQ requires a telehealth physician examination. Due to WA state regulations, you must be physically in WA state at the time of the DBQ exam.)* This field is required.

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 explain in the next screen)

List the In-service Event(s), Exposure(s), or Duties You Believe Caused or Contributed to the Claimed 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

What Was the Approximate Duration and Frequency of Exposure?

Has the VA Officially Conceded a Toxic Exposure Risk Activity (TERA) Related to Your Military Service?* This field is required.

Yes

I am not sure

The VA has acknowledged toxic exposure, but I am not sure whether it was formally documented as a TERA

Please Describe the TERA or Toxic Exposure the VA has Officially Conceded or Acknowledged.Examples may include exposure to burn pits, airborne hazards, fuels, solvents, PFAS/AFFF, pesticides, radiation, contaminated water, or other occupational/environmental hazards.

Medical Records You Plan to Submit.Check 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. (Note: Records exceeding 50 pages (25 pages for Level 0) incur additional fees, because time for physician review and analysis increases significantly with larger record sets. If you need help in choosing the most relevant records for your claim, please let us know.)* This field is required.

Under 25 pages

25-50 pages

Other

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, Please Provide 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 0: Medical Nexus Feasibility Review (fee credited towards future Level 2 or Level 3) 25-page limit.

Level 1: Medical Opinion Letter

Level 2: Comprehensive Medical Opinion Report (includes Medical Opinion Letter + Written Record Summary & Timeline Synthesis + List of Peer-Reviewed References)

Level 3. Comprehensive Medical Opinion Report (see Level 2 description) + 30-minute Physician Conference

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.Typical turnaround time is 2-3 weeks. If you have an upcoming deadline, we still may be able to meet it; additional fees to expedite will apply.

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

How Did You Learn About Us?

Facebook

Internet search

Referred by another Veteran

AI referral (ChatGPT, Claude, Gemini, etc.)

Other

Veteran/Representative Name* This field is required.

Please sign to submit your form.* This field is required.

Date Submitted* This field is required.

Date

Please verify that you are human* This field is required.

DMS Nexus Letter Intake Form