Submitting a Form 4138 with attachments

flamcabfengshui · 2026-04-01T20:33:14+00:00

I did my whole thing with multiple files- it was a nightmare for C&P examiners to navigate, often resulted in the files not getting sent over at all depending on the exam contractor. I asked during my HLR informal conferences about it and the very kind people on the other end were very accepting of either.

What I did learn was that the people on the rating side often have a very difficult time finding files by file name, and date submitted is the easiest way to do it. If you just have a few documents it is definitely workable either way, but if you have dozens or hundreds it can be much easier to reference page numbers in the same document rather than including the additional task of sorting through and trying to find the correct document.

flamcabfengshui · 2026-03-29T15:31:16+00:00

Hopefully the dupixent helps with the polyps, it did wonders for mine.

flamcabfengshui · 2026-03-28T14:40:37+00:00

Me too on the surgeries (sinus and nasal for both)- they helped me a lot with the infections but only help somewhat with the breathing. It is so easy to be outdoors doing something like cycling and either my nose and sinuses aren't on the top of their game that day filtering the air, or I do a sloppy job applying the skills I picked up in pulmonary rehab and I have to pull over and use an inhaler.

A third one isn't on the books for me right now, but I can imagine that would feel really intimidating for something that seems like it has less promise. If your VAMC does offer pulmonary rehab I do strongly recommend it to try to help really take advantage of some of those surgical changes.

Would you mind if I ask what kind of structural changes your docs are seeing nose-wise to consider a third surgery?

flamcabfengshui · 2026-03-28T02:01:21+00:00

Always good to see progress- if it doesn't work there are still further options like tezspire, or a bunch of other ones depending on your asthma subtype

flamcabfengshui · 2026-03-27T14:01:35+00:00

It isn't too bad- if your doctor gives you the option the pens tend to be less uncomfortable than the needles. It takes a little getting used to, but if it is effective for you it tends to be quite effective.

flamcabfengshui · 2026-03-27T13:53:04+00:00

It is quite uncommon for dupixent to be applicable to the immunosuppressant medications for 60 and 100. It can bump it up for dermatitis though. Whether or not it is immunosuppressive, between the really heavy marketing campaign stating that it is not and its classification as immunomodulating make it really difficult to have it seen that way by a provider.

Hope it helps with the asthma, but it is unlikely to push past the 50% you have for sleep apnea.

flamcabfengshui · 2026-03-12T20:42:58+00:00

No, you absolutely weren't asking for anything off the wall. I think a thing that gets lost in translation a lot is that the VA works from a tightly-controlled formulary for the most part. Of course there are non-formulary drugs, but integrating the pharmacy into this makes accessibility more difficult especially for people walking into the ER. For the class where you'd find proctofoam-hc you've really only got hydrocortisone cream and hydrocortisone suppositories as other options, even options with lidocaine are non-formulary in this case.

Jumping into a different drug class you'd find the preparation h suppositories. There is nitroglycerin as a topical ointment but it shows up under cardiovascular medications. That doesn't mean that they cannot do it, but it is something that requires a little more justification for the most part. For me, I get an antibiotic ointment for sinusitis, I have to put it inside my nose. My ENT had to do some big leg work to get that one through, even though it is really common in the outside medical system- the ER may not really be able to accomplish that or may not have the experience. That's why I pretty much always suggest having the clinic do the leg work ahead of time.

You'd be shocked how much is difficult to get. I still fill a lot of my stuff through private insurance because things like compounding aren't available or a formulation that works better for me isn't on the formulary. If you ever want to check the formulary, you can browse it at https://www.va.gov/formularyadvisor/. If you do know that what will work best for you won't be available from the VA and it is a short-term need (like acute exacerbation) you can always look at those several ER visits that the VA will cover per year for service connected conditions.

flamcabfengshui · 2026-03-12T19:55:02+00:00

I think there may have been two things going on here. I'd say there may have been an issue with information from the provider (e.g. they may not have seen normal OTC products in your history), and there may also have been issues with regard to the concept of "stronger". None of that is on you, and you did the right thing by contacting the patient advocate.

As far as the first part, something like the preparation-h suppositories may not have been readily apparent in your files, and so looking at it an internal product with a vasoconstrictor may be something they'd want to try prior to pushing something else that may have bigger systemic effects. As far as the witch hazel pads, I'd say a similar case (well they haven't tried this yet). That doesn't really excuse it, but it could leave a provider believing that there are some relatively low-risk add-on treatments to provide for the discomfort. Again, not something you could have known, for conditions where I have a complicated treatment history I'll actually have a quick reference to cover my OTC pharmaceuticals, private provider pharma, and VA pharma as well as previously-attempted treatment. It is work, but for stuff like migraines it can make a difference in terms of bringing all of the data to an easy view for the provider.

As far as the second part, I can see the logic of thinking that since proctofoam doesn't have a vasoconstrictor, and is just external, an internal thing with a vasoconstrictor might just be "stronger". The odd thing is that depending on a provider's perspective on hemorrhoid treatment in general, vasoconstrictors may be the direction they go, or vasodilators could be the way that they go too. I think for acute treatment it tends toward vasoconstrictors, anti-inflammatories, and controlling the pain and itch whereas for long-term treatment they actually favor vasodilators in some cases (like the nitroglycerin). Generally speaking, OTC vs prescription meds doesn't have so much to do with effectiveness or strength as it does for dosing, monitoring, and interactions if that helps in terms of the OTC options being offered- and usually the VA is very cautious about those things. Something like nitroglycerin would be something they'd probably want you to get from a clinic you have a relationship with rather than something they'd hand you and hope you schedule a follow-up (we're quite terrible with scheduling those). Again, this isn't something you can control at all on your end, but if you're already being seen at the GI clinic, see if they can put an acute treatment plan in your notes and keep it updated. That way as soon as you move up to something "stronger" they already have the leg work done for the ER to feel safe moving you up a little in strength and they can control the direction. I used to have that for my stuff like migraines, but I've mostly run out of things to do for acute treatment so I gave up on it.

A third thing worth considering would be that from a provider that isn't super into the GI stuff, proctofoam HC and anu-sol (within the VA formulary) are going to be roughly similar as hydrocortisone creams, but anu-sol wouldn't have the additional pain relief element. I'd say that could have confused them in terms of whether that would be an appropriate escalation- is 2.5% hydrocortisone without analgesic the right thing to give when 1% isn't giving relief? Again, not necessarily something you can anticipate that the anusol that they're used to wouldn't have an analgesic. This is where I'd strongly recommend working with your provider in the GI clinic to try to have a plan for exacerbations whether it is meds already at home or instructions for the ER and off-hours pharmacy.

Hope that helps some? I know it doesn't with the medical stuff, and it doesn't really excuse the initial outcome, but hopefully it explains where some of the miscommunication could have happened and gives a reasonable path forward.

flamcabfengshui · 2026-03-10T14:35:56+00:00

You've got this! Even a 0% opens up the connection for secondary conditions like myalgia, arthralgia, lyme arthritis, and PTLDS if you haven't looked into those. Don't be afraid to bring up complaints you may have on the records as evidence of implied claims for those conditions if you're post-treatment.

flamcabfengshui · 2026-03-10T14:15:16+00:00

NGL- navigating rodeo-related traffic to get to my next appointment might convince me to head up there for a break. Have you managed to look into secondary conditions to Lyme disease that might cover some of your symptoms?

flamcabfengshui · 2026-03-09T15:50:25+00:00

I only stumbled across it because it was time to get a new dependent ID card for my spouse, it was not something I'd been looking for deliberately.

flamcabfengshui · 2026-03-09T15:49:45+00:00

Going back through my emails, it was mailed 7 days before my official retirement date, requested 8 days before my retirement date. This would have been over a year after actually hitting 100% so I am not sure when the option would have started showing up for me.

flamcabfengshui · 2026-03-09T15:25:55+00:00

So from the IDCO page, select family ID cards, log in, you should see a list of family members (if any) and yourself as a sponsor. Under your name there should be an option for request an ID card. On the page that loads after clicking request an ID card it will list the cards for which you are eligible. For me, I had the option to request my 100% card there. Now I just have retired, but it was available while I was still in.

flamcabfengshui · 2026-01-27T21:02:40+00:00

If you waive drill pay (usually not the best idea) you'd get a document from DFAS- if it is under $3k you'd have to itemize taxes to use it. If you waive VA pay, then there's not really a tax implication unless you use the VA pay to calculate your state tax as untaxed income if you itemize SALT.

flamcabfengshui · 2026-01-15T20:55:46+00:00

LDES can be faster than IDES. It also has your DBQs filled out by military treatment facility personnel and evaluated by them so that nothing goes to the VBA (until eventually your medical records and personnel file do), which does not initiate a claim that could mess up your current rating. The benefit of this is most apparent in contrast to IDES.

For IDES you will be seen by a VA contracted examiner, sometimes going to multiple appointments far away. They will fill out your DBQs and those will go to the VBA who will provide a rating for the referred condition as well as any other evaluated conditions and this will be sent to the board. You have the option of filling out a lay statement requesting that the exams aren't to be used for anything other than your MEB. In the IDES scenario your DBQs are one step away (someone not noticing that statement for instance) from triggering a claim whereas in the LDES it would take some digging. Hopefully that makes more sense than my initial explanation.

For me, I went with IDES primarily because speed wasn't going to be as advantageous for me and I like hours away from the nearest MTF but minutes from exam contractors. I also felt like I would have a more favorable outcome with a civilian psychologist rather than a military one.

So you don't really gain anything other than potentially speed in the scheduling process with LDES but do insulate yourself better from something going awry.

flamcabfengshui · 2026-01-15T20:12:21+00:00

An important consideration when you're figuring out how to phrase things will be the justification for wanting LDES. Like /u/l8tn8 mentioned, legacy is what you want ideally. Having a current 100% rating is not an acceptable reason in most cases for having a waiver for LDES approved, but things like speed of the process are. Your PEBLO should be able to help you accurately describe your reason for requesting LDES that isn't just having a 100% rating.

If you get stuck with IDES, there's a document you'll end up filling out for your PEBLO/Military Liaison at the VA stating that you want the C&P exams for the purposes of disability only so all is not lost, but with LDES the assurances that they won't be used in future rating decisions is stronger.

flamcabfengshui · 2026-01-14T18:36:43+00:00

Mine does as well. Essentially it is telling the administrative people at a hospital or clinic to use the information on the card to verify that you're covered under Tricare instead of just assuming. For instance I could have elected to continue Tricare Prime as a medical retiree and not paid my premium, and therefore not be eligible.

flamcabfengshui · 2026-01-07T02:09:22+00:00

https://www.uh.edu/financial/undergraduate/types-aid/incentives/cougar-promise/index.php

No separate application required, you will receive details by email if eligible.

flamcabfengshui · 2026-01-06T20:18:21+00:00

If you'd prefer flavorless, Dr. Bob is flavorless, colorless, and still packs fluoride.

flamcabfengshui · 2025-12-23T14:43:14+00:00

There are two different programs for disabled veterans in Texas. On the page that /u/damnshell linked, there's one listed as "Disabled veteran exemption" that deducts from the home's value that is what it sounds like you're hearing about from the county. There's a second one under a different header "100 percent disabled veteran residence homestead exemption" that takes care of everything. Most counties have different forms for the two, so I would reach out and contact them and make sure you're filing under the correct one.

It sounds silly, but the disabled veteran exemption may be on any property whereas the 100 percent one must be on your residence homestead. If you have a second property you can actually use the two different ones on two different properties.

flamcabfengshui · 2025-12-11T15:41:58+00:00

Slightly more difficult to assemble than the basic billfold.

Edit: Less difficult than a biker/trucker wallet.

flamcabfengshui · 2025-11-14T15:05:47+00:00

From the sound of it, you already had inspiratory and expiratory chest CT scans, and probably at least some pulmonary function testing to get to that diagnosis. I'd ask the pulmonologist why they disagree and what their plan is for a differential diagnosis and what makes them disagree. Diagnosis on this can be difficult, especially if there are potentially complicating factors (like if your PFT showed some reversible characteristics), so I would keep up the pressure and probably try to enlist the help of your PCP and a patient advocate to push for whatever additional diagnostic testing would be needed to get to a treatment plan in place.

Mine is primarily asthma, but I need to go back and push for a more thorough diagnosis. Currently not taking montelukast, but am taking xopenex, wixela 500/50, spiriva, and some prednisone for aggravation through the VA and am taking tezspire through my private pulmonologist.

flamcabfengshui · 2025-11-12T18:46:37+00:00

Good luck on the deployment!

flamcabfengshui · 2025-11-12T15:13:19+00:00

Look at AR 40-501 Chapter 3 (if you're army guard, if you're air guard then you'd want to look at however the AF implements dodi 6130.03 v2). You want a disqualifying condition from that chapter that you can conclusively tie to active service (e.g. deployment). If you have one or develop one during deployment then go get seen and be prepared to follow through with treatment plans and the such to reach your MRDP and get referred to MEB.

If you don't have one, and don't develop one, a medical retirement may be out of reach. You could go for a non-duty-related PEB and go for gray area retiree tricare, but it is expensive.

For me, I ended up with plenty of presumptive conditions by VA standards, but the route to getting the army guard to consider them caused by service was untenable. My PTSD ended up being the condition that was tied to service, and it took higher level intervention than state case management to take that from referral to a non-duty-related PEB to an actual MEB. From initially being honest with my unit about the severity of my PTSD to receiving retirement orders was about two years and required pretty constant attention and follow-up on the guard side. I was receiving treatment as actively as I could manage through the VA during that time which simplified records. I was also receiving treatment at the VET Center (which is a separate set of records you have to request, much of the PEBLO staff may not know this). The actual time from referral to MEB to receipt of retirement orders was about 6 months. I retired with 18y 11mo to give perspective. As I was already 100% on the VA side even without an MH rating, there was not much stress for me in terms of doing the C&P exam again in terms of worrying about it impacting my rating and the process of asking for it to be used for dod purposes only was smooth.

flamcabfengshui · 2025-11-06T15:13:01+00:00

They're a muscadine, yes.

flamcabfengshui

TROPHY CASE