VA Form 20-0995, Decision Review Request: Supplemental Claim Completed Form Examples and Samples

Explore detailed examples of a filled VA Form 20-0995, Decision Review Request: Supplemental Claim. See how AI extracts information to complete sample forms for various disability claims, including PTSD, providing a clear guide for veterans and VSOs.
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Completed VA Form 20-0995, Decision Review Request: Supplemental Claim for PTSD

VA Form 20-0995 Example – Supplemental Claim for PTSD

How this form was filled:

Our AI successfully extracted all necessary details from a Veterans Service Officer (VSO) consultation summary email to automatically fill out VA Form 20-0995. This includes veteran identification, claim specifics, new evidence details, and acknowledgments, demonstrating intelligent data extraction from an unstructured narrative.

Source document used: Veterans Service Officer (VSO) Consultation Summary Email

Subject: Summary of our VA 20-0995 Consultation - John Smith

Dear John,

Great talking with you earlier today. As we discussed, I've prepared a summary for your review regarding the supplemental claim for VA Form 20-0995. This is for your service-connected PTSD, which we believe has worsened significantly since your last review.

First, let's confirm your personal details for the form. Your full name is John A. Smith, and your date of birth is March 15, 1978. Your Social Security Number is 987-65-4321, and your VA File Number is 123456789. For contact, we'll use your current mailing address: 123 Elm Street, Anytown, CA 90210, and your phone number (555) 123-4567. Your email, [email protected], will also be included for electronic notifications.

We're focusing this supplemental claim on Compensation benefits, specifically seeking service connection for your Post-Traumatic Stress Disorder (PTSD). Remember, the VA previously denied this claim with a decision notice dated August 20, 2023. We're confident the new evidence will turn this around.

For new and relevant evidence, we'll be submitting the therapy notes from your private provider, Dr. Emily White, at the Mind Health Clinic located in Los Angeles, CA. These notes cover your treatment from October 2023 through March 2024. You also mentioned getting that strong buddy statement from Sgt. Mark Johnson, your former squad mate, which will be crucial. I'll make sure to note that VA needs to obtain these medical records and the buddy statement on your behalf.

Just to confirm, you indicated that you are not currently homeless or at risk, so we can skip that section. Also, you confirmed reviewing the 5103 notice of evidence online, so we'll check 'Yes' for that. And regarding the MST question, as discussed, that section isn't applicable to your claim.

I'll prepare the form for your signature. Please let me know if any of these details need adjustment.

Best regards,

Sarah Connor
Veterans Service Officer

Information used to fill out the document:

  • Veteran Name: John A. Smith
  • Veteran DOB: 03/15/1978
  • Veteran SSN: 987-65-4321
  • Veteran VA File Number: 123456789
  • Veteran Mailing Address: 123 Elm Street, Anytown, CA 90210, United States
  • Veteran Phone: (555) 123-4567
  • Veteran Email: [email protected]
  • Benefit Type: Compensation
  • Specific Issue for Claim: Service connection for Post-Traumatic Stress Disorder (PTSD)
  • Date of VA Decision Notice: 08/20/2023
  • Homeless Status: No
  • Treatment Facility (New Evidence): Mind Health Clinic, Los Angeles, CA
  • Treatment Dates (New Evidence): October 2023
  • 5103 Notice Acknowledged: Yes
  • MST Notification Option: Not applicable and/or not enrolled or registered in VHA health care
  • Form Signed Date: 05/15/2024

What this filled form sample shows:

  • Extracted complete veteran identification details (name, DOB, SSN, VA File Number) from a conversational summary.
  • Correctly identified 'Compensation' as the benefit type and the specific disability 'Post-Traumatic Stress Disorder (PTSD)' for the claim.
  • Parsed the date of the previous VA decision (August 20, 2023) related to the denied claim.
  • Accurately extracted new evidence information, including the private healthcare provider's name, facility location, and treatment date range.
  • Identified the veteran's current mailing address and contact phone/email for form population.
  • Inferred responses for 'Homeless Status', '5103 Notice Acknowledgment', and 'MST Notification Option' based on the narrative.

Form specifications and details:

Use Case: Veteran filing a supplemental claim for service connection of PTSD with new medical evidence.
Source Document: VSO consultation summary email to veteran.
Categories: VA forms, VA claim forms
Created: March 10, 2026 04:01 AM
Completed VA Form 20-0995, Decision Review Request: Supplemental Claim for PTSD