4 Social Security Enter the SSN if it is different than the file Number (SSN) number. Enter the SSN of the person being Note: examined if the person is a Veteran. not 5 Telephone Number Enter the telephone number of the person being examined. 6 Power of Attorney Enter the power of attorney of the person being examined. 7 Date Ordered Enter the date on which the examination is requested. 8 By Enter the name or initials and VSR’s/RVSR’s Correspondence Symbol. 9 Type of Be sure to use the designated code to indicate Examination the examination type. Applicable codes are for Insufficient Exam “E” for Claim Increase “I” for Original Nonservice-Connected “ON” for Original Service-Connected “OS” for Other “OTH” for former POW “P” for Examination, and Review “R” for Terminal. “T” Continued on next page , Continued (continued) Item Entry Explanation 10 Insufficient If the request is for additional information Examination because a previous examination was insufficient, enter the following in the Remarks section: the date of the inadequate examination, and a complete explanation of the necessary corrective action. 11 General Medical Indicate any known diagnoses or complaints. Examinations
4 Social Security Number (SSN) Enter the SSN if it is different than the file number. Note: Enter the SSN of the person being examined if the person is not a Veteran. 5 Telephone Number Enter the telephone number of the person being examined. 6 Power of Attorney Enter the power of attorney of the person being examined. 7 Date Ordered Enter the date on which the examination is requested. 8 By Enter the VSR’s/RVSR’s name or initials and Correspondence Symbol. 9 Type of Examination Be sure to use the designated code to indicate the examination type. Applicable codes are “E” for Insufficient Exam “I” for Claim Increase “ON” for Original Nonservice-Connected “OS” for Original Service-Connected “OTH” for Other “P” for former POW “R” for Review Examination, and “T” for Terminal. Continued on next page , Continued (continued) Item Entry Explanation 10 Insufficient Examination If the request is for additional information because a previous examination was insufficient, enter the following in the Remarks section: the date of the inadequate examination, and a complete explanation of the necessary corrective action. 11 General Medical Examinations Indicate any known diagnoses or complaints.