Form VA Form 21-0985 VA Form 21-0985 Decision Ready Claim (DRC) Exam Request

OMB Control No. 2900-XXXX
Respondent Burden: 15 minutes
Expiration Date: XX/XX/XXXX

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

DECISION READY CLAIM (DRC) EXAM REQUEST
INSTRUCTIONS: Complete and submit this form in order to identify the disability(ies) that you would like the
Department of Veterans Affairs (VA) to request an examination for in preparation of filing a Decision Ready Claim
(DRC). VA reserves the right to confirm the authenticity of any information on this form or submitted with this form.
Please read the Privacy Act and Respondent Burden information on page 2 before completing this form.

SECTION I: VETERAN IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print your information using blue or black ink, neatly and legibly to help process the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

3. VA FILE NUMBER (If applicable)

2. VETERAN'S SOCIAL SECURITY NUMBER

4. VETERAN'S DATE OF BIRTH
Month

Day

Year

5. VETERAN'S SERVICE NUMBER (If applicable)

6. EMAIL ADDRESS (If applicable)

7. TELEPHONE NUMBER (Include Area Code)

SECTION II: DRC DISABILITY(IES)
(NOTE: See Example 4 for Claims for Increase)
8. LIST THE CURRENT DISABILITY(IES) THAT YOU WOULD LIKE TO REQUEST AN EXAMINATION FOR IN PREPARATION OF FILING YOUR DRC.
NOTE: List your claimed disability(ies) below. See the following examples for guidance on how to complete Section II.

4 EXAMPLES OF DISABILITY(IES)

2 EXAMPLES OF EXPOSURE

3 EXAMPLES OF HOW THE
DISABILITY(IES) RELATES

3 EXAMPLES OF
DATES

Example 1. HEARING LOSS

HAZARDOUS NOISE EXPOSURE

HEAVY EQUIPMENT OPERATOR IN SERVICE JULY 1968

Example 2. DIABETES

AGENT ORANGE

EXPOSED DURING VIETNAM WAR

DECEMBER 1972

INJURED KNEE WHEN RIGHT KNEE BRACE
FAILED

6/11/2008

Example 3. LEFT KNEE, SECONDARY TO RIGHT KNEE
Example 4. HYPERTENSION (currently service connected)

CURRENT DISABILITY(IES)

IF DUE TO EXPOSURE, EVENT, OR
INJURY, PLEASE SPECIFY
(i.e., Agent Orange, Radiation)

EXPLAIN HOW THE DISABILITY(IES)
RELATES TO THE IN-SERVICE
EVENT/EXPOSURE/INJURY

APPROXIMATE DATE
DISABILITY(IES)
BEGAN OR WORSENED

1.
2.
3.
4.
5.
6.
7.
8.
VA FORM
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21-0985

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VETERAN'S SOCIAL SECURITY NUMBER

SECTION II: DRC DISABILITY(IES) (Continued)
CURRENT DISABILITY(IES)

IF DUE TO EXPOSURE, EVENT, OR
INJURY, PLEASE SPECIFY
(i.e., Agent Orange, Radiation)

EXPLAIN HOW THE DISABILITY(IES)
RELATES TO THE IN-SERVICE
EVENT/EXPOSURE/INJURY

APPROXIMATE DATE
DISABILITY(IES)
BEGAN OR WORSENED

9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

19.

20.

SECTION III: CERTIFICATION AND SIGNATURE
I CERTIFY THAT the information I have given above is true and correct to the best of my knowledge and belief.
NOTE: A Power of Attorney's (POA) 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 POA is of record with VA.
9. EMAIL ADDRESS FOR POA (If assigned)

10. SIGNATURE OF VETERAN/POA OR ALTERNATE SIGNER (Sign in ink)

11. DATE SIGNED (MM/DD/YYYY)

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 benefits, verification of
identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and
Employment Records - VA, published in the Federal Register. Your obligation to respond is required in order to obtain the benefit. VA uses your Social Security number to
identify if you have a claim file and to ensure that your records are properly associated with your claim file. VA will not deny an individual benefits for refusing to provide his or
her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect.
RESPONDENT BURDEN: We need this information to determine which disability(ies) you would like VA to request an examination for in support of your Decision Ready
Claim (DRC). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 15 minutes to review the instructions, find the
information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to
a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If
desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
PENALTY: The law provides severe penalties which include fine or imprisonment, or both for the willful submission of any statement or evidence of a
material fact, knowing it to be false, or for the fraudulent acceptance of any payment to which you are not entitled.
VA FORM 21-0985, XXX XXXX

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