MILITARY MEDICAL RETIREMENT APPEAL

APPEAL TYPE

☐ Physical Evaluation Board (PEB) Formal Hearing Request
- Appeal of Informal PEB findings
- Must request within 10 calendar days of Informal PEB results

☐ Appeal to Service Secretary (Post-Formal PEB)
- Final appeal within military system
- Must request within 3 days of Formal PEB results

☐ Board for Correction of Military Records (BCMR) Application - DD Form 149
- Post-separation appeal
- Generally must file within 3 years of discovery (may be waived)

☐ Physical Disability Board of Review (PDBR) Application
- For members separated (not retired) between 9/11/2001 and 12/31/2009
- Combined rating was less than 30%

SECTION I: APPELLANT/APPLICANT INFORMATION

Full Legal Name: [________________________________]

Rank/Grade: [________________________________]

Service Number/SSN: [________________________________]

Date of Birth: [__/__/____]

Branch of Service: ☐ Army ☐ Navy ☐ Air Force ☐ Marine Corps ☐ Coast Guard ☐ Space Force

Component: ☐ Active Duty ☐ Reserve ☐ National Guard

Current Status: ☐ Active Duty ☐ Separated ☐ Retired

Current Address:
[________________________________]
[________________________________]
[________________________________]

Phone Number: [________________________________]

Email Address: [________________________________]

Current Unit (if still serving): [________________________________]

SECTION II: SERVICE INFORMATION

Date of Entry on Current Period of Service: [__/__/____]

Total Active Federal Service: [____] Years [____] Months [____] Days

Primary MOS/Rating/AFSC: [________________________________]

Current/Last Duty Station: [________________________________]

Deployment History:

SECTION III: MEDICAL EVALUATION BOARD (MEB) INFORMATION

Date of MEB Referral: [__/__/____]

MEB Convening Authority: [________________________________]

Date of MEB Findings: [__/__/____]

A. Conditions Referred to MEB

B. MEB Findings

☐ I agreed with MEB findings
☐ I disagreed with MEB findings
☐ I submitted a rebuttal dated [__/__/____]

MEB Narrative Summary (NARSUM) Date: [__/__/____]

SECTION IV: PHYSICAL EVALUATION BOARD (PEB) FINDINGS

A. Informal PEB Results

Date of Informal PEB: [__/__/____]

PEB Location: [________________________________]

Combined DoD Rating: [____]%

B. PEB Disposition Recommendation

☐ Return to Duty
☐ Separation with Severance Pay (less than 30% or less than 20 years service)
☐ Permanent Disability Retirement (30% or greater, or 20+ years)
☐ Temporary Disability Retired List (TDRL)
☐ Separation without Benefits

C. Formal PEB Results (if applicable)

Date of Formal PEB: [__/__/____]

Formal PEB Findings:
[________________________________]
[________________________________]
[________________________________]

SECTION V: INTEGRATED DISABILITY EVALUATION SYSTEM (IDES) INFORMATION

A. VA C&P Examination Information

Date of VA C&P Examination(s): [__/__/____]

VA Regional Office: [________________________________]

B. Proposed VA Ratings

Combined Proposed VA Rating: [____]%

SECTION VI: GROUNDS FOR APPEAL

A. Conditions Found Not Unfitting

☐ I contend the following condition(s) should have been found unfitting:

Explanation:
[________________________________]
[________________________________]
[________________________________]
[________________________________]

B. Rating Percentage Disputes

☐ I contend the following rating(s) are too low:

C. Line of Duty / Combat-Related Determinations

☐ I dispute the following Line of Duty determination(s):

☐ I dispute the following Combat-Related determination(s):

D. Existed Prior to Service (EPTS) Disputes

☐ I dispute the following EPTS determination(s):

E. Procedural Errors

☐ PEB failed to consider all relevant medical evidence
☐ MEB NARSUM was inaccurate or incomplete
☐ VA C&P examination was inadequate
☐ Physical Profile (PULHES) not properly considered
☐ Military Occupational Requirements not properly evaluated
☐ Other: [________________________________]

SECTION VII: DETAILED STATEMENT OF CASE

A. Medical History and Treatment

Date Condition(s) First Manifested:
[________________________________]

Timeline of Medical Treatment:
[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]

Current Treatment:
[________________________________]
[________________________________]

B. Functional Impairment

Describe how your condition(s) affect your ability to perform military duties:
[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]

C. Impact on Military Occupational Performance

Primary Duty MOS/Rating/AFSC Requirements:
[________________________________]

How Condition Prevents Performance:
[________________________________]
[________________________________]
[________________________________]
[________________________________]

D. Supporting Evidence for Higher Rating

VASRD Criteria (38 C.F.R. Part 4) Supporting Claimed Rating:
[________________________________]
[________________________________]
[________________________________]
[________________________________]

Medical Evidence Supporting Higher Rating:
[________________________________]
[________________________________]
[________________________________]
[________________________________]

SECTION VIII: RATING CRITERIA ANALYSIS

(Complete for each disputed condition)

Condition 1: [________________________________]

Current VASRD Code: [____]

Current Rating: [____]%

Claimed Rating: [____]%

Applicable Rating Criteria (from 38 C.F.R. Part 4):
[________________________________]
[________________________________]

Evidence Showing Criteria for Higher Rating Is Met:
[________________________________]
[________________________________]
[________________________________]
[________________________________]

Condition 2: [________________________________]

Current VASRD Code: [____]

Current Rating: [____]%

Claimed Rating: [____]%

Applicable Rating Criteria:
[________________________________]
[________________________________]

Evidence Showing Criteria for Higher Rating Is Met:
[________________________________]
[________________________________]
[________________________________]
[________________________________]

SECTION IX: DOCUMENTS IN SUPPORT OF APPEAL

A. Medical Records

☐ Service Treatment Records (Complete)
☐ MEB NARSUM
☐ VA C&P Examination Report(s)
☐ Informal PEB Decision
☐ Formal PEB Decision (if applicable)
☐ Military Physical Profile (DA 3349/equivalents)
☐ Commander's Performance Statement
☐ Line of Duty Investigation(s)
☐ Private Medical Records
☐ VA Medical Records
☐ Independent Medical Evaluation (IME)
☐ Medical Literature Supporting Position

B. Personnel Records

☐ DD-214 (if separated)
☐ Service Personnel Records
☐ Performance Evaluations
☐ Awards and Decorations
☐ Deployment Records
☐ Physical Fitness Test Results
☐ Duty Limitations Documentation

C. Other Supporting Documents

☐ Personal Statement
☐ Buddy Statements
☐ Command Statement(s)
☐ Family Member Statements
☐ Vocational Expert Opinion
☐ Other: [________________________________]

SECTION X: FORMAL PEB HEARING REQUEST

(Complete if requesting Formal PEB)

A. Hearing Type

☐ In-Person Hearing
☐ Video Teleconference (VTC) Hearing

Preferred Hearing Location: [________________________________]

B. Witness List

C. Request for Medical Expert

☐ I request appointment of a medical expert to testify regarding:
[________________________________]
[________________________________]

SECTION XI: REPRESENTATION

A. PEBLO (Physical Evaluation Board Liaison Officer)

PEBLO Name: [________________________________]

Contact: [________________________________]

B. Military Counsel

☐ I request appointment of military counsel

☐ I am represented by assigned military counsel:
- Name: [________________________________]
- Rank: [________________________________]
- Contact: [________________________________]

C. Civilian Counsel

☐ I am represented by civilian counsel at my own expense:
- Name: [________________________________]
- Bar Number: [________________________________]
- Address: [________________________________]
- Phone: [________________________________]
- Email: [________________________________]

D. Veterans Service Organization

☐ I am assisted by a VSO:
- Organization: [________________________________]
- Representative: [________________________________]
- Contact: [________________________________]

SECTION XII: TDRL CONSIDERATIONS

(Complete if placed on TEMPORARY Disability Retired List)

A. Current TDRL Status

Date Placed on TDRL: [__/__/____]

TDRL Rating: [____]%

Next TDRL Re-evaluation Date: [__/__/____]

B. TDRL Re-evaluation Appeal

☐ I am appealing a TDRL re-evaluation decision

Re-evaluation Findings:
[________________________________]
[________________________________]

Grounds for Appeal:
[________________________________]
[________________________________]

SECTION XIII: BCMR APPLICATION

(Complete if applying to Board for Correction of Military Records)

A. Timeliness

Date of Discovery of Error/Injustice: [__/__/____]

☐ Application is within 3 years of discovery
☐ Application is outside 3-year period - requesting waiver based on:
[________________________________]
[________________________________]

B. Exhaustion of Administrative Remedies

☐ All available administrative remedies were exhausted
☐ Administrative remedies were not exhausted because:
[________________________________]

C. Relief Requested from BCMR

☐ Change disability rating from [____]% to [____]%
☐ Change disposition from separation to retirement
☐ Add unfitting condition(s) to PEB findings
☐ Change Line of Duty determination
☐ Change Combat-Related determination
☐ Remove EPTS finding
☐ Correct effective date of retirement
☐ Other: [________________________________]

SECTION XIV: PDBR APPLICATION

(Complete if eligible for Physical Disability Board of Review)

A. Eligibility Verification

☐ I was separated (not retired) for disability
☐ Separation date was between 9/11/2001 and 12/31/2009
☐ Combined DoD disability rating was less than 30%

Date of Separation: [__/__/____]

DoD Combined Rating at Separation: [____]%

B. Conditions for PDBR Review

SECTION XV: REQUESTED RELIEF

I respectfully request:

☐ Increase disability rating for [________________________________] from [____]% to [____]%
☐ Change combined rating from [____]% to [____]%
☐ Find the following condition(s) unfitting: [________________________________]
☐ Change disposition from Separation to Permanent Disability Retirement
☐ Change disposition from Separation without Benefits to Separation with Severance
☐ Placement on TDRL instead of permanent retirement/separation
☐ Removal from TDRL to Permanent Disability Retirement
☐ Combat-Related Special Compensation (CRSC) eligibility determination
☐ Concurrent Retirement and Disability Pay (CRDP) eligibility determination
☐ Back pay and allowances from [__/__/____] to [__/__/____]
☐ Other relief: [________________________________]

SECTION XVI: FINANCIAL IMPACT STATEMENT

A. Current Benefits

Current Monthly Retired/Severance Pay: $[________________________________]

Current VA Disability Compensation: $[________________________________] at [____]%

B. Claimed Benefits

Claimed Monthly Retired Pay at [____]%: $[________________________________]

Difference: $[________________________________] per month

Retroactive Compensation Claimed: $[________________________________]

SECTION XVII: CERTIFICATION AND SIGNATURE

I certify that the statements made in this appeal are true and correct to the best of my knowledge and belief. I understand that making willfully false statements may subject me to punishment under the Uniform Code of Military Justice (if still serving) or federal criminal law.

Appellant Signature: [________________________________]

Printed Name: [________________________________]

Rank/Grade: [________________________________]

Date: [__/__/____]

SECTION XVIII: COUNSEL CERTIFICATION (if applicable)

I certify that I represent the above-named appellant and have reviewed this appeal.

Counsel Signature: [________________________________]

Printed Name: [________________________________]

Title/Organization: [________________________________]

Bar Number (if applicable): [________________________________]

Date: [__/__/____]

SUBMISSION ADDRESSES

Formal PEB Request:

Submit to your PEBLO within 10 calendar days of Informal PEB results

Service Secretary Appeal:

Submit to your PEBLO within 3 days of Formal PEB results

Board for Correction of Military Records (DD Form 149):

Army: Army Review Boards Agency, 251 18th Street South, Suite 385, Arlington, VA 22202-3531

Navy/Marine Corps: Board for Correction of Naval Records, 701 S. Courthouse Road, Suite 1001, Arlington, VA 22204-2490

Air Force/Space Force: SAF/MRBR, 3351 Celmers Lane, Joint Base Andrews, MD 20762-6435

Coast Guard: DHS Office of the General Counsel, Mail Stop 0485, 2707 Martin Luther King Jr. Ave SE, Washington, DC 20528

Physical Disability Board of Review:

SAF/MRBR, PDBR, 3351 Celmers Lane, Joint Base Andrews, MD 20762-6435
Or apply online at: https://afboardportal.azurewebsites.us/PDBR

IMPORTANT DEADLINES

• 10 Calendar Days: Request Formal PEB after Informal PEB results
• 3 Calendar Days: Appeal to Service Secretary after Formal PEB
• 3 Years: BCMR application (may be waived for good cause)
• PDBR: No deadline for eligible separations (9/11/2001 - 12/31/2009)

SOURCES AND REFERENCES

• DoD Instruction 1332.18 - Disability Evaluation System
• DoD Instruction 1332.38 - Physical Disability Evaluation
• VASRD - 38 C.F.R. Part 4 - Schedule for Rating Disabilities
• DD Form 149 - Application for Correction of Military Record
• Physical Disability Board of Review
• Military OneSource - Disability Evaluation System

This template is provided for educational and informational purposes. Service members facing medical separation or retirement should consult with their PEBLO, a military attorney, or a qualified civilian attorney specializing in military disability law.