IMPORTANT: Please read the information below carefully to help you complete this form quickly and accurately. Some
parts of the form also contain notes or specific instructions for completing that part.
Use this form to request a HIGHER-LEVEL REVIEW of the 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. 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 https://www.va.gov/decision-reviews/.
Submit your request for HIGHER-LEVEL REVIEW to the local VA office or processing center identified on your decision
notice letter. It is important that you keep a copy of all completed forms and materials you give to VA. This form has several
key components, which when filled out completely and accurately, will decrease the amount of time it takes to process your
HIGHER-LEVEL REVIEW request. This form may only be submitted for review of an issue(s) related to one benefit type
(Compensation, Pension/Survivors Benefits, Fiduciary, Insurance, Education, Loan Guaranty, Vocational Rehabilitation &
Employment, Veterans Health Administration, or National Cemetery Administration). If you would like to file for multiple
benefit types, you must complete a separate HIGHER-LEVEL REVIEW request for each benefit type.
You may contact your accredited representative (attorney, claims agent, and Veterans Service Organizations (VSOs)
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, VA-accredited attorneys, claims agents, and
VSO representatives is available at https://www.va.gov/ogc/apps/accreditation/index.asp
. Contact your local VA office for
assistance with appointing a representative or visit www.ebenefits.va.gov.
You can also ask VA to help you fill out the application by contacting us at the number provided on your decision notification
letter or at 1-800-827-1000. Before you contact us, please make sure you gather the necessary information and materials
(decision notification letter, etc.), and complete as much of the form as you can.
SPECIFIC INSTRUCTIONS FOR DECISION REVIEW REQUEST: HIGHER-LEVEL REVIEW
Part I - Claimant's Identifying Information
Please note that it would assist VA if you provide all the personal information in Part I. However, if you provide certain
information specific to the claimant such as the claimant's last name and Social Security Number or VA file number, VA will
be able to identify the claimant in our system and would not necessarily consider this request incomplete if other information
in Part I, such as the claimant's address and telephone number, is excluded. This request form may only be completed for
review of an issue(s) related to one benefit type. Select only one benefit type in item 12. If you would like to file for
multiple benefit types, you must complete a separate HIGHER-LEVEL REVIEW request form for each benefit type.
Part II - HIGHER-LEVEL REVIEW Options
You may request to have your HIGHER-LEVEL REVIEW conducted at either the same or a different office within the
agency of 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 decided
your issue(s). For a list of these issue types visit VA.gov/decision-reviews
. If we cannot fulfill your request, we will notify you
at the time the HIGHER-LEVEL REVIEW decision is made.
You or your appointed representative may request an informal conference with the higher-level reviewer assigned to
complete the review of your issue. The sole purpose of the optional telephone contact is to give you or your representative
the opportunity to identify any errors of fact or law in the prior decision. VA may make up to two attempts to call you at the
telephone number provided to VA to schedule your informal conference. If you would like VA to instead place the call to
schedule your informal conference to your VA authorized representative you must place the representative's name and
phone number in Box 14. If VA is unable to reach you or your representative, the higher-level reviewer will move forward
with completing your request for higher-level review and will issue a decision.
INFORMATION AND INSTRUCTIONS FOR COMPLETING DECISION REVIEW REQUEST: