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This form is to submit questions about published Clinical Determinations and Indications (CDIs). All other questions should be submitted to your local VA facility. Please DO NOT include PHI/PII information on this form. This form is NOT to be used to submit any other requests, including Request for Service (RFS); instructions for the RFS process are on the Care Coordination page. If PHI/PII has been submitted, then the provider must self report via Breach Reporting

Submitter Name

Submitter Phone Number

Submitter Email

Category of Care/ Medical Specialty

CDI Number

Ordering Provider Name

Ordering Provider Phone Number

Ordering Provider Email

Question Subject

Question

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Please do not submit PHI/PII through this form!

Submit a Clinical Determination and Indication (CDI) Question