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DBQ Provider Instructions

Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will use the information you provide on this Disability Benefits Questionnaire (DBQ) to process the Veteran's claim.

Important: VA will not pay or reimburse any expenses or costs incurred in the process of completing and/or submitting a DBQ. VA reserves the right to confirm the authenticity of all DBQs completed by private health care providers.



If your patient brings the DBQ, go to step 2.

If your patient requests you download the appropriate DBQ based on his or her claimed disability,

2 Complete the DBQ.
  • Follow all instructions carefully.
  • Legibility is important! Therefore, VA prefers you complete the DBQ electronically. If you complete a DBQ by hand, VA must be able to read the information.
  • You must complete the last section of the DBQ by providing your name, signature, and contact information. VA will only accept a DBQ signed by a licensed healthcare professional.
  • If you completed an electronic DBQ, you must print it to sign it.

Provide your patient with a copy of the completed DBQ for his or her records.


If you are a VA provider, skip to step 5.

If you are not a VA provider, your patient needs to complete a VA Form 21-4142 for "DBQ Purposes".
(This is so we can request additional information if clarification is needed.)


If your patient requests, submit the completed DBQ to VA.

  • Ask your patient to identify the VA Regional Office (RO) responsible for handling the claim.
  • You can submit the DBQ to that VA RO by fax or mail. You can find the RO's mailing address and fax number on the DBQ website.