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

INFORMATION AND INSTRUCTIONS FOR COMPLETING DECISION REVIEW REQUEST:
HIGHER-LEVEL REVIEW
IMPORTANT: Please read the information below carefully to help you complete this form accurately. Some parts of the form
also contain notes or specific instructions for completing that section.
USE THIS FORM TO REQUEST A HIGHER-LEVEL REVIEW OF A DECISION YOU RECEIVED. A Higher-Level Review is
a new review of an issue(s) previously decided by the Department of Veterans Affairs (VA) based on the evidence of record
at the time VA issued notice of the prior decision. The Higher-Level Reviewer will not consider any evidence received
after the notification date of the prior decision. A Higher-Level Review may not be requested for the review of a HigherLevel Review decision or a Board of Veterans' Appeals decision. This form must be submitted to VA WITHIN ONE YEAR
OF THE DATE VA PROVIDED NOTICE OF OUR DECISION. For additional information on the Higher-Level Review
process or a list of review options that allow VA to consider new evidence and how to file, visit
www.va.gov/decision-reviews/.
It is important you keep a copy of all completed forms and materials you give to VA. Filling out this form completely and
accurately will decrease the amount of time it takes to process your Higher-Level Review request.
You may contact your accredited representative (attorney, claims agent, and Veterans Service Organization (VSO)
representative) to assist you in completing this form. If you have not already selected a representative or if you want to
change your representative, a searchable database of VA-recognized VSOs, and VSO representatives as well as, VAaccredited attorneys and claims agents is available at www.va.gov/ogc/apps/accreditation/index.asp.
Submit your request for Higher-Level Review to the local VA office or processing center identified on your decision notice
letter. You can find mailing address information at www.va.gov/decision-reviews/higher-level-review/. You can ask VA
to help you fill out this application by contacting us at 1-800-827-1000. Before you contact us, gather the necessary
information and materials (decision notification letter, etc.) and complete as much of the form as you can.
You may request to have your Higher-Level Review conducted at either the same or a different office within the agency of
original jurisdiction that decided your issue(s). Please note that decisions on certain types of issues are processed at only a
single VA office or facility. Accordingly, some issues cannot be reviewed at an office other than the office that originally
decided your issue(s).

SPECIFIC INSTRUCTIONS FOR DECISION REVIEW REQUEST: HIGHER-LEVEL REVIEW
Section I - Veteran's Identification Information
Please note it would assist VA if you provide all the information to identify the veteran in Section I. However, if you provide
certain information specific to the veteran such as the last name and Social Security Number or VA file number, VA will be
able to identify the veteran and would not necessarily consider this request incomplete if other information in Section I, such
as the address and telephone number, is excluded.
If you are homeless or at risk of homelessness, mark the circle in item 6. If you wish to request priority processing for other
reasons, you may file VA Form 20-10207, Priority Processing Request, with this form.
Section II - Claimant's Identification Information (If other than veteran)
If the claimant is different than the veteran, fill out the information in Section II. Without this information, we will be unable to
identify the claimant. If you are a healthcare provider or agent or employee of a healthcare provider requesting review of a
VA payment decision, you must identify the healthcare provider as the claimant and complete all relevant information in the
claimant identification section.

VA FORM
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20-0996

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Section III - Benefit Type
This form may only be submitted for review of an issue(s) related to one benefit type: Compensation, Pension/Survivors
Benefits, Fiduciary, Life Insurance, Education, Loan Guaranty, Veteran Readiness and Employment, Veterans Health
Administration, or National Cemetery Administration. Select only one benefit type in item 15 (i.e. Compensation). If
you would like to file for multiple benefit types (i.e. Compensation and Life Insurance), you must complete a separate
Higher-Level Review request form for each benefit type. If your disagreement is with a decision by the Veterans Health
Administration, even if you are seeking reimbursement for medical expenses or non-VA emergency care, you must
select Veterans Health Administration in item 15.
Section IV - Optional Informal Conference
You or your appointed representative may request an informal conference with the Higher-Level Reviewer assigned to
complete the review of your issue(s) by marking the circle in item 16A. The sole purpose of the optional telephone
contact is to provide the opportunity to identify errors of fact or law in the decision(s) under review. Evidence that was
not of record at the time of the decision will not be considered. Choosing this option may delay issuance of a decision.
To avoid potential delays, you may submit a written statement that identifies errors of fact or law along with this
application form instead of requesting an informal conference.
VA will make two attempts to call you or your representative at the telephone number you provide to VA in order to
schedule your informal conference. If you would like VA to call your representative instead of calling you, you must
include the representative's name and phone number in items 17A and 17B. In order for VA to speak to your
representative on your behalf, a valid VA Form 21-22a, Appointment of Individual as Claimant's Representative or
VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative must be of record or
included with this application. If VA is unable to reach you or your representative after two attempts, the Higher-Level
Reviewer will move forward with completing your request for Higher-Level Review and issue a decision.
Section V - Issues for Higher-Level Review
The purpose of this section is for you to identify, in item 18A, each issue decided by VA that you would like as part of
your Higher-Level Review. You may choose to cite a specific area of disagreement for each issue, such as: entitlement
to service connection, a higher evaluation, or an earlier effective date. Please refer to your decision notification letter(s)
for a list of adjudicated issues. You should enter the date of VA's decision for each issue. Only those issue(s) that you
list on this form will be addressed during the Higher-Level Review. For those issues you do not list on this form, you still
have one year from the date of the decision notification letter to request a Higher-Level Review, or to have them
reviewed through a different review option.
If you are responding to a Statement of the Case (SOC) or Supplemental Statement of Case (SSOC) in the legacy
appeals system, you may elect to continue your appeal either in the legacy appeals system or in the modernized review
system. Your decision notice contains further details. To participate in the modernized review system, you must submit
this form within 60 days from the date of the SOC or SSOC and list the issue(s) in the SOC or SSOC for which you are
seeking review under item 18A. Your selection of the Higher-Level Review option does not prevent you from changing
the review option (in accordance with applicable procedures) before VA renders the Higher-Level Review decision on an
issue. You cannot return to the legacy system for any issue(s) you withdraw. Note: This is a change from previous
versions of this form which required marking an opt-in box to elect participation into the modernized review system.
Section VI - Certification and Signature
Please be sure to sign this request for Higher-Level Review, certifying the statements on this form are true and
correct to the best of your knowledge and belief. Be sure to sign the form in ink. Forms not signed in ink may be
returned. For alternate signer certification please include VA Form 21-0972, Alternate Signer Certification.
Section VII - Authorized Representative Signature
A VA authorized representative may sign this section in lieu of the veteran or claimant signature in section VII, as long
as a valid VA Form 21-22 or VA Form 21-22a, is of record or included with this application.

VA FORM 20-0996, XXXX

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OMB Control No. 2900-0862
Respondent Burden: 15 minutes
Expiration Date: 4/30/2024
VA DATE STAMP
DO NOT WRITE IN THIS SPACE

DECISION REVIEW REQUEST: HIGHER-LEVEL REVIEW
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 5.
Use this form to request a Higher-Level Review of a decision you received. A Higher-Level Review is a new
review of an issue(s) previously decided by VA based on the evidence of record at the time of the prior
decision. For more information call us toll-free at 1-800-827-1000. If you use a Telecommunications Device
for the Deaf (TDD), the Federal relay number is 711. VA forms are available at https://www.va.gov/find-forms/.

SECTION I - VETERAN'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, insert one letter
per box, and completely fill in each applicable circle to help expedite processing of the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

4. DATE OF BIRTH (MM/DD/YYYY)

3. VA FILE NUMBER (If applicable)

5. VA INSURANCE POLICY NUMBER (If applicable)

6. CURRENT MAILING ADDRESS (Number, street or rural route, City or P.O. Box, State and ZIP Code and Country)
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

I AM HOMELESS OR AT RISK OF HOMELESSNESS
7. TELEPHONE NUMBER (Include Area Code)
Enter International Phone Number (If applicable)
8. E-MAIL ADDRESS (Optional)

SECTION II - CLAIMANT'S IDENTIFICATION INFORMATION (If other than veteran)
9. CLAIMANT'S NAME (First, Middle Initial, Last)

11. DATE OF BIRTH (MM/DD/YYYY) (If applicable)

10. SOCIAL SECURITY NUMBER (If applicable)

12. CURRENT MAILING ADDRESS (Number, street or rural route, City or P.O. Box, State and ZIP Code and Country)
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

13. TELEPHONE NUMBER (Include Area Code)
Enter International Phone Number (If applicable)
14. E-MAIL ADDRESS (Optional)

SECTION III - BENEFIT TYPE
15. SELECT ONLY ONE (If you file for multiple benefit types, you must complete a separate VA Form 20-0996 for each benefit type.)
COMPENSATION

PENSION/DIC/SURVIVORS BENEFITS

VETERAN READINESS AND EMPLOYMENT
VA FORM
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20-0996

FIDUCIARY

EDUCATION

VETERANS HEALTH ADMINISTRATION

LOAN GUARANTY

LIFE INSURANCE

NATIONAL CEMETERY ADMINISTRATION

SUPERSEDES VA FORM 20-0996, APR 2021

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SECTION IV - OPTIONAL INFORMAL CONFERENCE
16. YOU OR YOUR AUTHORIZED REPRESENTATIVE MAY REQUEST AN INFORMAL CONFERENCE WITH THE HIGHER-LEVEL REVIEWER FOR THE SOLE
PURPOSE OF POINTING OUT ERRORS OF FACT OR LAW IN THE PRIOR DECISION. (VA will only conduct one informal conference by telephonic communication
associated with this request for Higher-Level Review.)
16A. I WOULD LIKE AN INFORMAL CONFERENCE. I understand electing an informal conference is optional and may delay a decision.
16B. IF YOU SELECTED THE BOX ABOVE, VA will make two attempts to contact you OR your representative to schedule the informal conference. Contact attempts
will be between the hours of 8:00 a.m. and 4:30 p.m. Eastern Time. INDICATE ONE PREFERENCE:
Call me between 8:00 a.m. - 12:00 p.m. ET

Call me between 12:00 p.m. - 4:30 p.m. ET

Call my representative between 8:00 a.m. - 12:00 p.m. ET

Call my representative between 12:00 p.m. - 4:30 p.m. ET

17. IF YOU WOULD LIKE VA TO CONTACT YOUR REPRESENTATIVE, YOU MUST PROVIDE YOUR REPRESENTATIVE'S CONTACT INFORMATION BELOW.
17A. REPRESENTATIVE'S NAME (First, Last)

17B. REPRESENTATIVE'S TELEPHONE NUMBER (Include Area Code)

17C. REPRESENTATIVE'S E-MAIL ADDRESS

SECTION V - ISSUES FOR HIGHER-LEVEL-REVIEW
18. If you are responding to a Statement of the Case (SOC) or a Supplemental Statement of the Case (SSOC): By submitting this form, I agree to participate in the modernized
review system for the following issues decided in a SOC or SSOC. I am withdrawing the eligible appeal issues listed in 18A in their entirety, and any associated hearing
requests, from the legacy appeals system. I understand I cannot return to the legacy appeals system for the issue(s) withdrawn.
INDICATE EACH ISSUE DECIDED BY VA FOR WHICH YOU ARE REQUESTING A HIGHER-LEVEL REVIEW. Refer to your decision notice(s) for a list of adjudicated
issues. For each issue, identify the date of VA's most recent decision on the issue. You may attach additional sheets, if necessary - include your name and file number on
each additional sheet. IMPORTANT: You may only list issues for the benefit type selected in Section III. A separate form is required for each benefit type.
18A. SPECIFIC ISSUE(S) OF DISAGREEMENT (REQUIRED)
Example 1:
Example 2:
Example 3:
Example 4:
Example 5:

Service connection for left knee
Earlier effective date for hearing loss
Reimbursement for non-VA emergency care
Denial of entitlement to VR&E benefits and services
Entitlement to Service-Disabled Veterans Insurance

VA FORM 20-0996, XXXX

18B. DATE OF VA DECISION NOTIFICATION
LETTER (REQUIRED)
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY

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SECTION V - ISSUES FOR HIGHER-LEVEL REVIEW (Continued)
18B. DATE OF VA DECISION NOTIFICATION
LETTER (REQUIRED)

18A. SPECIFIC ISSUE(S) OF DISAGREEMENT (REQUIRED)

SECTION VI - CERTIFICATION AND SIGNATURE
NOTE: This section is MANDATORY and completion is required to process your claim unless accompanied by VA Form 21-0972, Alternate Signer
Certification or Section VII is completed.
I CERTIFY the statements on this form are true and correct to the best of my knowledge and belief.
19A. SIGNATURE OF VETERAN OR CLAIMANT (Sign in ink)

19B. DATE SIGNED

SECTION VII - AUTHORIZED REPRESENTATIVE SIGNATURE
I CERTIFY the statements on this form are true and correct to the best of my knowledge and belief.
NOTE: A representative's 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 representative is of record with VA or included with this application.
20A. NAME OF VA AUTHORIZED REPRESENTATIVE (First, Last)

20B. SIGNATURE OF VA AUTHORIZED REPRESENTATIVE (Sign in ink)

20C. DATE SIGNED

PENALTY: The law provides severe penalties which include a fine, imprisonment, or both, for the willful submission of any statement or evidence of a
material fact, knowing it to be false.
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 VA 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 voluntary.
RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). 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 the
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.
VA FORM 20-0996, XXXX

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