Intake Form: Records Correction IMO / David Medical Services

Thank you for your interest in Records Correction Independent Medical Opinions by David Medical Services. Our physicians provide independent, evidence-based medical opinions for Veterans and former service members seeking correction of military records, including matters involving medical separation, disability evaluation, fitness for duty, and disability retirement.

This intake form helps us understand your request, determine whether it falls within our physicians' areas of expertise, and identify the appropriate scope of medical review.

Important: We provide independent medical evaluations and opinions, not legal representation. Submission of this form does not establish a physician-patient relationship or guarantee that a favorable medical opinion can be supported.

Please provide concise answers. Our staff may request additional information before confirming whether we can accept your case.

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

Service Member / Veteran

Attorney / Legal Representative

Family Member

Other

Representative's full name* This field is required.

Relationship to service member* This field is required.

Law firm or organization (if applicable)

Are you authorized to communicate with us regarding this matter?* This field is required.

Service member's full legal name* This field is required.

First name

Last name

Rank or preferred form of address

Email address* This field is required.

example@example.com

Phone number* This field is required.

Please enter a valid phone number.

Current state of residence * This field is required.

List city and country if outside the US

Preferred method of contact

Phone

Either method is fine

Branch of military service* This field is required.

Army

Navy

Air Force

Marine Corps

Coast Guard

Space Force

National Guard

Reserve Component

Other

Dates of military serviceMonth/Year to Month/Year

Military Occupational Specialty (MOS), Rating, or AFSC* This field is required.

Highest rank / grade held

Type of discharge* This field is required.

Honorable

General

Other Than Honorable

Medical Separation

Medical Retirement

Administrative Separation

Other

Date of separation or retirement* This field is required.

Date

Were you serving on active duty, in the Reserve, or in the National Guard when the medical issue arose?

Active Duty

Reserve

National Guard

Other

What type of military records correction are you seeking?* This field is required.Select all that apply.

Correction of Medical Separation or Disability Retirement Status

Retroactive Medical Retirement

Referral to the Disability Evaluation System (DES/MEB/PEB)

Correction of a Fitness-for-Duty or Unfitness Determination

Correction of Medical Findings or Diagnoses

Correction of Disability Rating or Medical Retirement Determination

Correction of Discharge Characterization Involving Medical Issues

Correction of Service Treatment or Personnel Records

Other

Which board or authority is reviewing, or will review, your case?

Army Board for Correction of Military Records (ABCMR)

Board for Correction of Naval Records (BCNR)

Air Force Board for Correction of Military Records (AFBCMR)

Coast Guard Board for Correction of Military Records

Discharge Review Board

Not Yet Filed / Unsure

Other

What is the current status of your case?* This field is required.

Preparing an Initial Application

Application Submitted; Decision Pending

Previously Denied; Seeking Reconsideration

Reconsideration Submitted; Decision Pending

Other

If previously reviewed, what was the date of the most recent decision?

Date

Board Docket or Case Number (if applicable)

Briefly describe the specific correction you are requesting.

Is there a filing deadline or scheduled hearing?

Yes

Unsure

If you answered "yes" to the previous question, please provide date.

Date

What medical condition or conditions are central to your records correction request, and when were they first diagnosed?* This field is required.List provider-diagnosed medical condition(s) relevant to the records correction request, and the approximate year you were diagnosed with the condition.

How did these conditions affect your ability to perform military duties at the time?* This field is required.Please describe relevant duty limitations, profiles, restrictions, hospitalizations, or inability to perform assigned responsibilities.

What do you believe was medically incorrect or overlooked in the original military decision?* This field is required.For example, a diagnosis that was not considered, failure to evaluate functional limitations, or medical findings that were inconsistent with the available records.

Were you evaluated by a Medical Evaluation Board (MEB) or Physical Evaluation Board (PEB)?

Yes

Unsure

Were you placed on a permanent medical profile or given formal duty restrictions?

Yes

Unsure

Was a medical opinion or advisory opinion used in the decision that you want independently reviewed?

Yes

Unsure

Briefly describe the medical conclusion you believe requires further review.

Has a military records correction board previously denied your request?* This field is required.

YESNO

If yes, what was the primary reason for denial?Please summarize the board's stated rationale, particularly any medical findings or conclusions.

Do you have new medical evidence that was not considered in the previous decision?* This field is required.

Yes

Unsure

Not applicable

If yes, briefly describe the new evidence.Examples include previously unavailable medical records, imaging, hospitalization records, specialist evaluations, or documentation correcting the original medical timeline.

Are you requesting that our physician evaluate or respond to an unfavorable medical advisory opinion?* This field is required.

Yes

Unsure

Which of the following records do you currently have available?Select all that apply.

Military Service Treatment Records

Military Personnel Records

Medical Profiles or Duty Restrictions

MEB / PEB Findings

Separation or Retirement Documents (DD214, Orders)

Prior Records Correction Board Decision

Medical Advisory Opinion Used by the Board

VA Disability Rating Decisions

Relevant Civilian Medical Records

New Medical Evidence Not Previously Considered

Other

Approximately how many pages of relevant records do you anticipate submitting for physician review?* This field is required.

25 pages or less

26-50 pages

51-100 pages

101-200 pages

More than 200 pages

Unsure

Have you already organized the relevant records into a focused set for physician review?

Yes

In Progress

Are there specific records you have been unable to obtain?

YESNO

If yes, briefly identify the missing records.

What specific medical question would you like our physician to address?* This field is required.

Whether the medical evidence supported referral to the Disability Evaluation System

Whether a medical condition affected fitness for military duty

Whether relevant medical evidence was overlooked or incorrectly interpreted

Whether an unfavorable medical advisory opinion is consistent with the evidence

Whether the documented medical condition and functional limitations support reconsideration of a separation or retirement decision

Whether new medical evidence changes the prior medical assessment

Other

Are you seeking an opinion regarding medical fitness or disability status at the time of separation?

Yes

Unsure

Are you requesting an opinion involving multiple medical conditions?

YESNO

What outcome are you hoping the independent medical opinion will help support?Please briefly describe the requested records correction or medical determination.

Is there anything else our physicians should know when evaluating your request? Please limit your response to information relevant to the medical issues and requested correction.

Which Service Level are you seeking?* This field is required.Please visit our website or call us for more information on these levels.

IMO-1: Records Review + Fitness Opinion

IMO-2: Comprehensive Fitness Opinion + Medical Timeline

IMO-3: Comprehensive Opinion + Timeline + Interview by Physician

I'm not sure. Help me choose.

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

I understand that this service provides an independent medical opinion based on available records.

I understand that David Medical Services does not provide legal representation or legal advice.

I understand that completion of this intake form does not constitute acceptance of my case or initiation of a medical records review.

I understand that acceptance of my request depends on the medical issues involved, the available evidence, and the physician's professional expertise.

I understand that I am requesting an independent medical opinion, which may identify evidence supporting or not supporting the requested correction. A favorable conclusion is not guaranteed.

I understand that professional fees and any applicable additional records-review charges will be communicated before paid services begin.

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

I confirm that the information provided is accurate to the best of my knowledge and that I am authorized to submit it.

I authorize David Medical Services to contact me or my designated representative regarding this request using the contact information provided.

Signature* This field is required.

Date submitted* This field is required.(Today's date)

Date

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

Intake Form: Records Correction IMO / David Medical Services