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VA Form 20-0995: Decision Review Request: Supplemental Claim

VA Form 20-0995 asks VA to take another look at a decided claim based on new and relevant evidence, from a fresh medical record to a lay statement VA has not seen before.

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What is VA Form 20-0995?

VA Form 20-0995, Decision Review Request: Supplemental Claim, is the decision review option for claimants who have evidence VA did not consider in its prior decision. VA reviews the issue again with the new and relevant evidence added to the record, and its duty to assist applies, so VA will help gather records you identify.

The form lists the issues you want reviewed, the new evidence you are submitting, and any private treatment records you want VA to request on your behalf. It is used across VA benefit lines, and disability compensation Supplemental Claims can also be filed online at va.gov.

Who files VA Form 20-0995?

Veterans who disagree with a VA decision and have new and relevant evidence to add
Claimants whose Higher-Level Review or Board appeal was denied and who have new evidence
Survivors and dependents seeking review of a decided benefit claim
Representatives filing a Supplemental Claim for a claimant

How to fill out VA Form 20-0995

Enter your identifying information and the benefit type the claim relates to.
List each issue you want VA to review and the date of the prior decision.
Identify the new and relevant evidence you are submitting, and complete the authorization section if you want VA to request private treatment records.
Sign and date the form.
Mail it to the VA Claims Intake Center address in the form instructions, upload it through va.gov, or file a compensation Supplemental Claim online.

Quick fill VA Form 20-0995 on this page

Prefer to see the form itself while you type? Open VA Form 20-0995 in the editor to fill it on the actual pages, add a signature, and download.

These are the form's own fields, in the order they appear on the pages. Fill in what you know; anything left blank stays a fillable field in the PDF, so you can finish it in any PDF reader. Nothing you type here is sent to VA.

Page 4 46 fields

Read Instructions above. 1. BENEFIT TYPE (PLEASE CHECK ONLY ONE BOX). Read Note above. COMPENSATION.

1. If Veterans Health Administration is checked, specify which benefit type you are claiming for V H A. (e.g., Travel / Mileage

SECTION 1 - VETERAN'S IDENTIFYING INFORMATION. See Note above. 2. Veteran's Name (First, Middle Initial, Last). Enter First Name. 12

2. Veteran's Name. Enter Middle Initial. 1 character max.

2. Veteran's Name. Enter Last Name. 18 characters max.

3. SOCIAL SECURITY NUMBER. Enter First Three Digits.

3. SOCIAL SECURITY NUMBER. Enter Middle Two Digits.

3. SOCIAL SECURITY NUMBER. Enter Last Four Digits.

4. V. A. FILE NUMBER (if applicable). Enter nine digit file number.

5. DATE OF BIRTH. Enter 2 digit Month.

5. DATE OF BIRTH. Enter 2 digit day.

5. DATE OF BIRTH. Enter 4 digit year.

6. VETERAN'S SERVICE NUMBER (If applicable). Enter 9 digit number.

7. V. A. INSURANCE POLICY NUMBER (If applicable).

8. MAILING ADDRESS (Number, street or rural route, P.O. Box, City, State, ZIP Code and Country). Number and Street. 30 characters max.

8. MAILING ADDRESS. Apartment or Unit Number. 5 characters max.

8. MAILING ADDRESS. City. 18 characters max.

8. MAILING ADDRESS. State or Province. 2 characters max.

8. MAILING ADDRESS. Country. 2 characters max.

8. MAILING ADDRESS. ZIP or Postal Code. First 5 digits.

8. MAILING ADDRESS. ZIP or Postal Code. Last 4 digits.

9. TELEPHONE NUMBER (Include Area Code). Enter three digits of Area Code.

9. TELEPHONE NUMBER (Include Area Code). Enter middle three digits.

9. TELEPHONE NUMBER (Include Area Code). Enter last four digits.

9. Enter International Phone Number (If applicable).

10. E-MAIL ADDRESS (Optional).

SECTION 2: CLAIMANT'S IDENTIFICATION INFORMATION (Complete this section ONLY IF the claimant is NOT the veteran). Read Note above. 11.

11. CLAIMANT'S NAME. Enter Middle Initial. 1 character max.

11. CLAIMANT'S NAME. Enter Last Name. 18 characters max.

12. SOCIAL SECURITY NUMBER. Enter First Three Digits.

12. SOCIAL SECURITY NUMBER. Enter Middle Two Digits.

12. SOCIAL SECURITY NUMBER. Enter Last Four Digits.

13. V. A. FILE NUMBER (if applicable). Enter nine digit file number.

14. DATE OF BIRTH. Enter 2 digit Month.

14. DATE OF BIRTH. Enter 2 digit day.

14. DATE OF BIRTH. Enter 4 digit year.

15. V. A. INSURANCE POLICY NUMBER (If applicable).

16. RELATIONSHIP TO VETERAN (Check one). SPOUSE.

16. Specify Other Relationship.

17. MAILING ADDRESS (Number, street or rural route, P.O. Box, City, State, ZIP Code and Country). Number and Street. 30 characters max.

17. MAILING ADDRESS. Apartment or Unit Number. 5 characters max.

17. MAILING ADDRESS. City. 18 characters max.

17. MAILING ADDRESS. State or Province. 2 characters max.

17. MAILING ADDRESS. Country. 2 characters max.

17. MAILING ADDRESS. ZIP or Postal Code. First 5 digits.

17. MAILING ADDRESS. ZIP or Postal Code. Last 4 digits.

Page 5 47 fields

18. TELEPHONE NUMBER (Include Area Code). Enter three digits of Area Code.

18. TELEPHONE NUMBER (Include Area Code). Enter middle three digits.

18. TELEPHONE NUMBER (Include Area Code). Enter last four digits.

18. Enter International Phone Number (If applicable).

19. E-MAIL ADDRESS (Optional).

20. A. NO (If "No," skip to Item 21).

20B. WHICH OF THESE STATEMENTS BEST DESCRIBES YOUR LIVING SITUATION? (Select all that apply). I LIVE OR SLEEP IN A PLACE THAT IS NOT MEANT

20B. I LIVE IN A SHELTER (e.g., a hotel or motel that is meant for temporary stays).

20B. I AM STAYING WITH A FRIEND OR FAMILY MEMBER, BECAUSE I AM UNABLE TO OWN A HOME RIGHT NOW.

20B. IN THE NEXT 30 DAYS, I WILL HAVE TO LEAVE A FACILITY, LIKE A HOMELESS SHELTER.

20B. IN THE NEXT 30 DAYS, I WILL LOSE MY HOME (Note: This selection includes any house, apartment, trailer, or other living space that you

20B. NONE OF THESE SITUATIONS APPLY TO ME (Note: We understand that you may have other housing risks not listed here. If you feel

20B. OTHER (Specify).

20B. Specify other living situation.

20C. POINT OF CONTACT (Name of person V. A. can contact in order to get in touch with you).

20D. POINT OF CONTACT TELEPHONE NUMBER (Include Area Code). Enter three digits of Area Code.

20D. POINT OF CONTACT TELEPHONE NUMBER (Include Area Code). Enter middle three digits.

20D. POINT OF CONTACT TELEPHONE NUMBER (Include Area Code). Enter last four digits.

20D. Enter International Phone Number (If applicable).

SECTION 4: ISSUE(S) FOR SUPPLEMENTAL CLAIM. 21. YOU MUST LIST EACH ISSUE DECIDED BY V. A. THAT YOU WOULD LIKE V. A. TO REVIEW AS PART OF

21B. DATE OF V. A. DECISION NOTICE. Enter 2 digit Month. Line 1 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 2 digit day. Line 1 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 4 digit year. Line 1 of 7.

21. A. SPECIFIC ISSUE(S). Line 2 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 2 digit Month. Line 2 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 2 digit day. Line 2 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 4 digit year. Line 2 of 7.

21. A. SPECIFIC ISSUE(S). Line 3 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 2 digit Month. Line 3 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 2 digit day. Line 3 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 4 digit year. Line 3 of 7.

21. A. SPECIFIC ISSUE(S). Line 4 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 2 digit Month. Line 4 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 2 digit day. Line 4 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 4 digit year. Line 4 of 7.

21. A. SPECIFIC ISSUE(S). Line 5 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 2 digit Month. Line 5 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 2 digit day. Line 5 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 4 digit year. Line 5 of 7.

21. A. SPECIFIC ISSUE(S). Line 6 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 2 digit Month. Line 6 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 2 digit day. Line 6 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 4 digit year. Line 6 of 7.

21. A. SPECIFIC ISSUE(S). Line 7 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 2 digit Month. Line 7 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 2 digit day. Line 7 of 7.

21B. DATE OF V. A. DECISION NOTICE. Enter 4 digit year. Line 7 of 7.

Page 6 21 fields

SECTION 5: NEW AND RELEVANT EVIDENCE. Read Important information above. 22. A. IDENTIFY WHERE YOU HAVE RECEIVED TREATMENT (Check all that

22. A. V. A. VET CENTER.

22. A. COMMUNITY CARE (Paid for by V. A.).

22. A. V. A. MEDICAL CENTER(S) (V. A. M. C. ) AND COMMUNITY-BASED OUTPATIENT CLINICS (C B O C).

22. A. DEPARTMENT OF DEFENSE (D O D) MILITARY TREATMENT FACILITY(IES) (M T F).

22. A. OTHER (Specify).

22. A. Specify other location where you received treatment.

Read Note above. 22B. NAME AND LOCATION OF THE TREATMENT FACILITY. Line 1 of 3.

22C. DATE(S) OF TREATMENT (Approximate dates are acceptable). Enter 2 digit Month. Line 1 of 3.

22C. DATE(S) OF TREATMENT. Enter 4 digit year. Line 1 of 3.

22D. CHECK THE BOX IF YOU DO NOT HAVE DATE(S) OF TREATMENT. DON'T HAVE DATE. Line 1 of 3.

22B. NAME AND LOCATION OF THE TREATMENT FACILITY. Line 2 of 3.

22C. DATE(S) OF TREATMENT (Approximate dates are acceptable). Enter 2 digit Month. Line 2 of 3.

22C. DATE(S) OF TREATMENT. Enter 4 digit year. Line 2 of 3.

22D. CHECK THE BOX IF YOU DO NOT HAVE DATE(S) OF TREATMENT. DON'T HAVE DATE. Line 2 of 3.

22B. NAME AND LOCATION OF THE TREATMENT FACILITY. Line 3 of 3.

22C. DATE(S) OF TREATMENT (Approximate dates are acceptable). Enter 2 digit Month. Line 3 of 3.

22C. DATE(S) OF TREATMENT. Enter 4 digit year. Line 3 of 3.

22D. CHECK THE BOX IF YOU DO NOT HAVE DATE(S) OF TREATMENT. DON'T HAVE DATE. Line 3 of 3.

SECTION 6: 5103 NOTICE OF ACKNOWLEDGMENT (This section applies to Compensation, Pension, D I C, and Accrued benefit claims only) (Note: If

SECTION 7: OPTION FOR VETERANS BENEFITS ADMINISTRATION (V. B. A.) TO NOTIFY VETERANS HEALTH ADMINISTRATION (V. H. A.) ABOUT CERTAIN

Page 7 17 fields

25B. DATE SIGNED. Enter 2 digit Month.

25B. DATE SIGNED. Enter 2 digit day.

25B. DATE SIGNED. Enter 4 digit year.

26B. PRINTED NAME AND ADDRESS OF FIRST WITNESS. Enter Name.

26B. PRINTED NAME AND ADDRESS OF FIRST WITNESS. Enter Address.

27B. PRINTED NAME AND ADDRESS OF SECOND WITNESS. Enter Name.

27B. PRINTED NAME AND ADDRESS OF SECOND WITNESS. Enter Address.

28B. DATE SIGNED. Enter 2 digit Month.

28B. DATE SIGNED. Enter 2 digit day.

28B. DATE SIGNED. Enter 4 digit year.

29B. DATE SIGNED. Enter 2 digit Month.

29B. DATE SIGNED. Enter 2 digit day.

29B. DATE SIGNED. Enter 4 digit year.

29C. ACCREDITATION NUMBER.

29D. DATE LAST V. A. FORM 21-22 OR V. A. FORM 21-22 A. WAS SUBMITTED (If known). Enter 2 digit Month.

29D. DATE LAST V. A. FORM 21-22 OR V. A. FORM 21-22 A. WAS SUBMITTED (If known). Enter 2 digit day.

29D. DATE LAST V. A. FORM 21-22 OR V. A. FORM 21-22 A. WAS SUBMITTED (If known). Enter 4 digit year.

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Frequently asked questions

What counts as new and relevant evidence?

Evidence VA did not have when it decided the claim, and that tends to prove or disprove something at issue. Examples include new medical records, a nexus opinion from a doctor, or lay statements. Restating the same facts already in the file is not enough.

Is there a deadline for a Supplemental Claim?

You can file one at any time, but filing within one year of the prior decision generally protects your effective date for benefits. After a year, benefits are typically paid from the new filing date instead. Check the current instructions at va.gov.

Will VA help me get the evidence?

Yes. Unlike Higher-Level Review, the duty to assist applies to Supplemental Claims. If you identify records, including private treatment records on the authorization section, VA will attempt to obtain them.

VA Form 20-0995: Decision Review Request: Supplemental Claim

What is VA Form 20-0995?

Who files VA Form 20-0995?

How to fill out VA Form 20-0995

Quick fill VA Form 20-0995 on this page

Frequently asked questions

Related forms

VA Form 20-0996: Decision Review Request: Higher-Level Review

VA Form 10182: Decision Review Request: Board Appeal (Notice of Disagreement)

VA Form 21-4138: Statement in Support of Claim