Specialist Examinations Check this box to request a specialist examination. Attach a copy of any Board of Veterans’ Appeals (BVA) remand if the examination is required in connection with a remand. Explain the nature of the examination and Note: the reason for the request in the Remarks section. Remarks Restrict entries to clarifying remarks concerning the issue or issues to be resolved and/or the type of examination requested. Do not use manual, regulation, or code Note: citations. Claimant Represented Indicate by an appropriate check or annotation, By the current accredited service organization of record. If the person being examined is Note: represented by a person or organization that does have an office located at the RO not check the block in Item 19 ,and “Other” enter the complete name and address of the person or organization. Enter the Date Signature of date the form is signed Authorizing Official, and name of the authorizing official (must be legible), and Correspondence Symbol correspondence symbol and telephone number of the authorizing official. Continued on next page , Continued c. Forwarding Forward the examination request to the clinic or medical center nearest the Examination residence that is able to conduct the type of examination requested. Veteran’s Requests to the Appropriate Reverse file a copy of the examination request in the claims folder pending d. Handling the File Copy of receipt of the examination report. the Examination Request
Specialist Examinations Check this box to request a specialist examination. Attach a copy of any Board of Veterans’ Appeals (BVA) remand if the examination is required in connection with a remand. Note: Explain the nature of the examination and the reason for the request in the Remarks section. Remarks Restrict entries to clarifying remarks concerning the issue or issues to be resolved and/or the type of examination requested. Note: Do not use manual, regulation, or code citations. Claimant Represented By Indicate by an appropriate check or annotation, the current accredited service organization of record. Note: If the person being examined is represented by a person or organization that does not have an office located at the RO check the “Other” block in Item 19 ,and enter the complete name and address of the person or organization. Date Signature of Authorizing Official, and Correspondence Symbol Enter the date the form is signed name of the authorizing official (must be legible), and correspondence symbol and telephone number of the authorizing official. Continued on next page , Continued c. Forwarding Examination Requests to the Appropriate Forward the examination request to the clinic or medical center nearest the Veteran’s residence that is able to conduct the type of examination requested. d. Handling the File Copy of the Examination Request Reverse file a copy of the examination request in the claims folder pending receipt of the examination report.