VA Form 4107VHA Your Rights to Appeal Our Decision

What Is VA Form 4107VHA?

VA Form 4107VHA, Your Rights to Appeal Our Decision is a document describing how to appeal decisions made by the Veterans Health Administration (VHA). It covers health benefit (medical) appeals which include outpatient treatment, eligibility for hospitalization, nursing home, and domiciliary care. The VHA is the largest health care system in the United States which enrolls more than 9 million veterans across the country.

The latest version of VA 4107VHA form was released by the Department of Veterans Affairs (VA) in June 2016 with all previous editions obsolete. A printable VA Form 4107VHA fillable version is available for download or can be found through the VA website.

This form applies to three categories of claims:

  • Claims related to enrollment issues - beneficiary travel, priority group assignment, etc.;
  • Claims related to prosthetic services - structural alterations, home improvements;
  • Claims related to the treatment not authorized by the VA.
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YOUR RIGHTS TO APPEAL OUR DECISION
After careful and compassionate consideration, a decision has been reached on your claim. If we were not
able to grant some or all of the VA benefits you asked for, this form will explain what you can do if you
disagree with our decision. If you do not agree with our decision, you may:
Start an appeal by telling us you disagree with our decision.
Give us evidence we do not already have that may lead us to change our decision.
This form will tell you how to appeal and how to send us more evidence. You can do either one or both of
these things.
H
C
I A
D
OW
AN
PPEAL THE
ECISION?
How do I start my appeal? To begin your appeal, write us a letter telling us you disagree with our decision.
This letter is called your "Notice of Disagreement." If we denied more than one claim for a benefit, please tell
us in your letter which claims you are appealing. Send your Notice of Disagreement to the address included
on our decision notice letter.
How long do I have to start my appeal? You have one year to start an appeal of our decision. Your letter
saying that you disagree with our decision must be postmarked (or received by us) within one year from the
date of our letter denying you the benefit. In most cases, you cannot appeal a decision after this one-year
period has ended.
What happens if I do not start my appeal on time? If you do not start your appeal on time, our decision
will become final. Once our decision is final, you cannot get the VA benefit we denied unless you either:
Show that we were clearly wrong to deny the benefit or
Send us new evidence that relates to the reason we denied your claim.
What happens after VA receives my Notice of Disagreement? We will either grant your claim or send you
a Statement of the Case. A Statement of the Case describes the facts, laws, regulations, and reasons that we
used to make our decision. We will also send you a VA Form 9, "Appeal to Board of Veterans' Appeals," with
the Statement of the Case. If you want to continue your appeal to the Board of Veterans' Appeals (Board)
after receiving a Statement of the Case, you must complete and return the VA Form 9 within one year from the
date of our letter denying you the benefit or within 60 days from the date that we mailed the Statement of the
Case to you, whichever is later. If you decide to complete an appeal by filing a VA Form 9, you have the
option to request a Board hearing. Hearings often increase wait time for a Board decision. It is not necessary
for you to have a hearing for the Board to decide your appeal. It is your choice.
Where can I find out more about the VA appeals process?
You can find a "plain language" pamphlet called "How Do I Appeal," on the Internet at:
http://www.bva.va.gov/How_Do_I_Appeal.asp.
You can find the formal rules for the VA appeals process in title 38, Code of Federal Regulations,
Part 20. You can find the complete Code of Federal Regulations on the Internet at:
http://www.ecfr.gov. A printed copy of the Code of Federal Regulations may be available at your
local law library.
Y
R
R
OUR
IGHT TO
EPRESENTATION
Can I get someone to help me with my appeal? Yes. You can have a Veterans Service Organization
representative, an attorney-at-law, or an "agent" help you with your appeal. You are not required to have
someone represent you. It is your choice.
Representatives who work for accredited Veterans Service Organizations know how to prepare and
present claims and will represent you. You can find a listing of these organizations on the Internet at
http://www.va.gov/vso.
VA FORM
4107VHA
(Please continue reading on page 2)
JUN 2016
YOUR RIGHTS TO APPEAL OUR DECISION
After careful and compassionate consideration, a decision has been reached on your claim. If we were not
able to grant some or all of the VA benefits you asked for, this form will explain what you can do if you
disagree with our decision. If you do not agree with our decision, you may:
Start an appeal by telling us you disagree with our decision.
Give us evidence we do not already have that may lead us to change our decision.
This form will tell you how to appeal and how to send us more evidence. You can do either one or both of
these things.
H
C
I A
D
OW
AN
PPEAL THE
ECISION?
How do I start my appeal? To begin your appeal, write us a letter telling us you disagree with our decision.
This letter is called your "Notice of Disagreement." If we denied more than one claim for a benefit, please tell
us in your letter which claims you are appealing. Send your Notice of Disagreement to the address included
on our decision notice letter.
How long do I have to start my appeal? You have one year to start an appeal of our decision. Your letter
saying that you disagree with our decision must be postmarked (or received by us) within one year from the
date of our letter denying you the benefit. In most cases, you cannot appeal a decision after this one-year
period has ended.
What happens if I do not start my appeal on time? If you do not start your appeal on time, our decision
will become final. Once our decision is final, you cannot get the VA benefit we denied unless you either:
Show that we were clearly wrong to deny the benefit or
Send us new evidence that relates to the reason we denied your claim.
What happens after VA receives my Notice of Disagreement? We will either grant your claim or send you
a Statement of the Case. A Statement of the Case describes the facts, laws, regulations, and reasons that we
used to make our decision. We will also send you a VA Form 9, "Appeal to Board of Veterans' Appeals," with
the Statement of the Case. If you want to continue your appeal to the Board of Veterans' Appeals (Board)
after receiving a Statement of the Case, you must complete and return the VA Form 9 within one year from the
date of our letter denying you the benefit or within 60 days from the date that we mailed the Statement of the
Case to you, whichever is later. If you decide to complete an appeal by filing a VA Form 9, you have the
option to request a Board hearing. Hearings often increase wait time for a Board decision. It is not necessary
for you to have a hearing for the Board to decide your appeal. It is your choice.
Where can I find out more about the VA appeals process?
You can find a "plain language" pamphlet called "How Do I Appeal," on the Internet at:
http://www.bva.va.gov/How_Do_I_Appeal.asp.
You can find the formal rules for the VA appeals process in title 38, Code of Federal Regulations,
Part 20. You can find the complete Code of Federal Regulations on the Internet at:
http://www.ecfr.gov. A printed copy of the Code of Federal Regulations may be available at your
local law library.
Y
R
R
OUR
IGHT TO
EPRESENTATION
Can I get someone to help me with my appeal? Yes. You can have a Veterans Service Organization
representative, an attorney-at-law, or an "agent" help you with your appeal. You are not required to have
someone represent you. It is your choice.
Representatives who work for accredited Veterans Service Organizations know how to prepare and
present claims and will represent you. You can find a listing of these organizations on the Internet at
http://www.va.gov/vso.
VA FORM
4107VHA
(Please continue reading on page 2)
JUN 2016
A private attorney or an "agent" can also represent you. VA only recognizes attorneys who are
licensed to practice in the United States or in one of its territories or possessions. Your local bar
association may be able to refer you to an attorney with experience in veterans' law. An agent is a
person who is not a lawyer, but who VA recognizes as being knowledgeable about veterans' law.
Contact us if you would like to know if there is a VA accredited agent in your area.
Do I have to pay someone to help me with my appeal? It depends on who helps you. The following
explains the differences.
Veterans Service Organizations will represent you for free.
Attorneys or agents can charge you for helping you under some circumstances. Paying their fees for
helping you with your appeal is your responsibility. If you do hire an attorney or agent to represent
you, a copy of any fee agreement must be sent to VA. The fee agreement must clearly specify if VA
is to pay the attorney or agent directly out of past-due benefits. See 38 C.F.R. § 14.636(g)(2). If the
fee agreement provides for the direct payment of fees out of past-due benefits, a copy of the direct-
pay fee agreement must be filed with us at the address included on our decision notice letter within 30
days of its execution. A copy of any fee agreement that is not a direct-pay fee agreement must be
filed with the Office of the General Counsel within 30 days of its execution by mailing the copy to
the following address: Office of the General Counsel (022D), Department of Veterans Affairs, 810
Vermont Avenue, NW., Washington, DC 20420. See 38 C.F.R. § 14.636(g)(3).
G
VA A
E
IVING
DDITIONAL
VIDENCE
You can send us more evidence to support a claim whether or not you choose to appeal
NOTE: Please direct all new evidence to the address included on our decision notice letter. You should not
send evidence directly to the Board at this time. You should only send evidence to the Board if you decide
to complete an appeal and, then, you should only send evidence to the Board after you receive written
notice from the Board that they received your appeal.
If you have more evidence to support a claim, it is in your best interest to give us that evidence as soon as you
can. We will consider your evidence and let you know whether it changes our decision. Please keep in mind
that we can only consider new evidence that: (1) we have not already seen and (2) relates to your claim. You
may give us this evidence either in writing or at a personal hearing with your local VA office.
In writing. To support your claim, you may send documents and written statements to us at the address
included on our decision notice letter. Tell us in a letter how these documents and statements should
change our earlier decision.
At a personal hearing. You may request a hearing with an employee at your local VA office at any time,
whether or not you choose to appeal. We do not require you to have a local hearing. It is your choice. At
this hearing, you may speak, bring witnesses to speak on your behalf, and hand us written evidence. If you
want a local hearing, send us a letter asking for a local hearing. Use the address included on our decision
notice letter. We will then:
Arrange a time and place for the hearing
Provide a room for the hearing
Assign someone to hear your evidence
Make a written record of the hearing
W
H
A
I G
VA E
HAT
APPENS
FTER
VIDENCE?
IVE
We will review any new evidence, including the record of the local hearing, if you choose to have one,
together with the evidence we already have. We will then decide if we can grant your claim. If we cannot
grant your claim and you complete an appeal, we will send the new evidence and the record of any local
hearing to the Board.
SUPERSEDES VA FORM 4107VHA, JUN 2015,
BACK OF VA FORM 4107VHA, JUN 2016
WHICH WILL NOT BE USED.

Download VA Form 4107VHA Your Rights to Appeal Our Decision

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Your Right to Appeal Our Decision

There are two types of appeals and, respectively, two different appeal paths to take:

  • A clinical appeal - when a veteran is denied a form of treatment or a particular medication; and
  • An administrative appeal - when a veteran appeals an administrative decision, for example, a denial of medical service, because a veteran does not qualify for the VA care.

According to Form 4107VHA VA, to start the appeal process a veteran must send the VA a Notice of Disagreement. If desired, a veteran can give the VA additional evidence relating to the claim to show them they were clearly wrong in denying the benefit. The VA reviews the new evidence along with the information they already have and replies with a Statement of the Case - a document outlining the reasoning behind their initial decision. The VA also sends a copy of VA Form 9, Appeal to Board of Veterans' Appeals. A veteran has an option to request a Board hearing to complete an appeal.

VA Decision Appeal form mentions veterans' right to representation. Veterans can get someone to help with the appeal process. It can be a representative from the Veterans Service Organization, an attorney, or an «agent». The latter two can charge a veteran for their services, and it is a veteran's responsibility to pay. On the contrary, Veterans Service Organizations will help a veteran for free.

VA Appeal Form 4107 Series

The Department of Veterans Affairs VA Form 4107VHA has four other related forms:

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