Nexus Letter Guide: Free Template & Examples for VA Claims (2026)

A nexus letter is often the difference between approval and denial. This guide shows you exactly what a nexus letter needs, who can write one, and how to get a letter that satisfies VA standards.

1. Understand the standard: Learn the "at least as likely as not" language that meets 38 CFR requirements.
2. Find the right provider: Know who qualifies to write nexus letters and how to approach them.
3. Build an airtight letter: Use our template and examples to ensure your nexus letter has every required element.

A nexus letter is a medical opinion that connects your current disability to your military service. The term "nexus" means link or connection—and that's exactly what this document provides: the medical bridge between what happened during service and the condition you have today.

Under 38 CFR § 3.303, the VA requires three elements for service connection:

1. Current disability: A medical diagnosis of your claimed condition
2. In-service event: Evidence that something happened during service (injury, illness, exposure, or onset of symptoms)
3. Nexus: A medical opinion linking your current condition to that in-service event

The nexus letter addresses the third element. Without it, veterans often lose claims even when they clearly have a condition and service records showing an in-service event. The VA needs a qualified medical professional to state that the connection between the two is "at least as likely as not"—meaning 50% or greater probability.

This standard comes from 38 CFR § 3.102, the benefit of the doubt rule. When evidence is in equipoise (50/50), the tie goes to the veteran. That's why "at least as likely as not" is the magic phrase—it meets the threshold for VA approval.

Many veterans assume their medical records and service treatment records speak for themselves. Unfortunately, the VA often needs explicit medical reasoning to grant service connection. Here's when a nexus letter becomes critical:

When C&P Exam Opinion Is Unfavorable

VA Compensation & Pension examiners sometimes provide negative opinions, stating your condition is "less likely than not" related to service. A well-reasoned private nexus letter can counter this opinion and provide the VA with a basis to rule in your favor.

Secondary Service Connection Claims

If you're claiming a condition caused or aggravated by an already service-connected disability, you need a nexus letter explaining the medical relationship. See our Secondary Condition Claim Playbook for the full strategy.

Reopening Denied Claims

When filing a Supplemental Claim after a denial, a new nexus letter often constitutes the "new and relevant evidence" required to reopen your case—especially if the prior denial cited lack of nexus.

Conditions Without Clear Documentation

Some conditions develop gradually or weren't documented in service treatment records (STRs). A nexus letter from a specialist who understands the condition's typical progression can explain why symptoms might not appear until years after service.

Under 38 CFR § 3.159(a)(1), competent medical evidence must come from "a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions."

Strongest Providers

• Medical Doctors (MD) and Doctors of Osteopathy (DO): Carry the most weight, especially specialists in the relevant field (orthopedist for joint claims, psychiatrist for mental health, etc.)
• Specialists: A letter from a specialist in the condition you're claiming is more persuasive than one from a general practitioner

Accepted Providers

• Nurse Practitioners (NP) and Physician Assistants (PA): Their opinions are accepted, though some VA raters may give them slightly less weight than physicians
• Psychologists (PhD, PsyD): Fully qualified for mental health nexus opinions
• Audiologists: Qualified for hearing-related conditions

Scope-Limited Providers

• Chiropractors: Can provide nexus opinions for conditions within their scope of practice—primarily musculoskeletal issues like back, neck, and joint conditions. Under 38 CFR § 3.159(a)(1), competent medical evidence is determined by whether the provider is “qualified through education, training, or experience” to offer the specific medical opinion. A well-reasoned chiropractor nexus letter for a spine condition may be accepted by the VA, though typically carries less weight than opinions from MDs or DOs. Chiropractor opinions for conditions outside their scope (mental health, neurological, systemic medical conditions) will likely be rejected. The opinion must review medical records and provide reasoning based on medical principles, not just transcription of the veteran’s statements.
• Acupuncturists and unlicensed alternative providers: Generally not considered qualified to provide nexus opinions under VA regulations, though treatment records may be submitted as evidence

Cannot Request Nexus Letters From

• VA C&P examiners: You cannot request a nexus letter from them—they provide opinions only during official exams
• Veterans themselves: Self-written medical opinions have no probative value

Why VA Doctors Often Refuse

Many veterans are surprised when their VA primary care provider declines to write a nexus letter. VA employees are often discouraged from providing opinions for claims purposes due to potential conflicts of interest. This doesn't reflect on your case—it's an institutional policy. You'll likely need a private provider or an Independent Medical Opinion (IMO) service.

A nexus letter that gets your claim approved includes all five of these elements. Miss one, and the VA may assign it low probative weight or reject it entirely.

1. Provider Credentials and CV

The letter should clearly state the provider's qualifications: medical degree, board certifications, specializations, and years of experience. Attaching a CV or curriculum vitae adds credibility. The VA needs to see why this provider is qualified to render an opinion on your specific condition.

2. Complete Records Review Statement

The provider must state that they reviewed relevant medical records. This typically includes:

• Service treatment records (STRs)
• VA medical records
• Private treatment records
• Any prior C&P exam reports

A letter that says "based on my examination" without a records review is weaker than one demonstrating the provider considered your full medical history.

3. "At Least as Likely as Not" Language

This exact phrase (or equivalent) is required. The opinion must state that the connection between your condition and service is 50% or greater probability. Acceptable variations include:

Speculative language like "may," "could," or "possibly" does not meet the VA's standard and will be assigned little to no probative weight.

4. Evidence-Based Medical Rationale

The opinion must explain why the connection exists. This is where many nexus letters fail. The provider should:

• Cite specific findings from the records review
• Reference medical literature or studies when applicable
• Explain the medical mechanism connecting service to the current condition
• Address any gaps in documentation and explain why they don't break the chain

A one-sentence conclusion without reasoning carries little weight. The VA wants to see the medical logic.

5. Clear Conclusion with Diagnostic Codes

End with an unambiguous conclusion that directly answers the nexus question. Including the relevant VA diagnostic code shows the provider understands VA rating criteria. For example: "It is my opinion that the veteran's lumbar degenerative disc disease (DC 5242) is at least as likely as not caused by the documented back injury during his military service in 2015."

Nexus letters serve different purposes depending on whether you're claiming direct or secondary service connection. The language must match your claim type.

Direct (Primary) Service Connection

Under 38 CFR § 3.303, direct service connection requires linking your current condition to an in-service event, injury, or disease. The nexus letter must explain how what happened during service caused your current disability.

Example nexus statement: "It is at least as likely as not that the veteran's bilateral hearing loss is the result of acoustic trauma during his service as an artillery crew member from 2008-2012, as documented in his MOS noise exposure history."

Secondary Service Connection (Causation)

Under 38 CFR § 3.310(a), a disability that is "proximately due to or the result of a service-connected disease or injury shall be service connected." The nexus letter must explain how your already-rated condition caused the new condition.

Example nexus statement: "It is at least as likely as not that the veteran's major depressive disorder is proximately due to his service-connected chronic lumbar pain, which has caused sleep disruption, activity limitation, and decreased quality of life as documented in his treatment records."

Secondary Service Connection (Aggravation)

Under 38 CFR § 3.310(b), if a service-connected condition worsened (aggravated) a non-service-connected condition, the aggravation can be service connected. This requires establishing the baseline severity before aggravation occurred.

Example nexus statement: "It is at least as likely as not that the veteran's pre-existing hypertension has been permanently aggravated beyond its natural progression by his service-connected PTSD. Prior to PTSD onset, blood pressure was consistently 130/85; following PTSD diagnosis, readings have averaged 155/95 despite medication adjustments."

For full guidance on secondary claims, see the Secondary Condition Claim Playbook and use our Secondary Conditions Finder to identify potential secondary claims.

Veterans often confuse nexus letters with Disability Benefits Questionnaires (DBQs). They serve different purposes:

When You Need Both

For many claims, you benefit from having both:

• The DBQ confirms you have the condition and documents its severity for rating purposes
• The nexus letter provides the medical reasoning connecting it to service

Some providers combine both into a single comprehensive report. This can be effective, but ensure the nexus portion includes all five essential elements discussed above.

DBQ Availability (February 2026)

As of February 2026, the majority of DBQs (50+) are publicly available for any licensed provider to complete. Only 11 DBQs are restricted to VA examiners due to specialized training requirements or federal regulations (including Cold Injury Residuals, Former POW Protocol, General Medical examinations, Initial PTSD evaluation, Hearing Loss and Tinnitus, and TBI evaluations).

Note: The VA temporarily removed all DBQs from public view in April 2020 citing fraud concerns, but reinstated most DBQs in March 2021. The Veterans Benefits Improvement Act of 2024 codified the requirement for VA to maintain publicly available DBQs. Check the VA's DBQ library for current availability.

The following examples demonstrate proper nexus letter language. Adapt them to your specific circumstances—never submit a generic letter without personalization.

Direct Connection Example

After reviewing [Veteran's Name]'s service treatment records, VA medical records, and conducting a physical examination on [Date], it is my professional medical opinion that his current diagnosis of degenerative disc disease of the lumbar spine (DC 5242) is at least as likely as not the result of his military service.

Service records document a back injury in March 2014 during a training exercise, with subsequent complaints of lower back pain on three occasions before separation. Medical literature establishes that traumatic injuries to the spine frequently lead to accelerated degenerative changes. The progression from documented acute injury to current degenerative findings follows the expected clinical course.

Secondary Connection Example

Based on my review of [Veteran's Name]'s complete medical records and examination findings, it is at least as likely as not that her obstructive sleep apnea is proximately due to her service-connected PTSD (rated 70%).

Peer-reviewed research demonstrates a significant association between PTSD and sleep apnea. The hyperarousal symptoms of PTSD disrupt normal sleep architecture, and the medications commonly prescribed for PTSD (as documented in her pharmacy records) can contribute to weight gain and upper airway muscle relaxation. Her sleep study conducted in 2024 confirms moderate obstructive sleep apnea with an AHI of 22, consistent with this pathophysiological mechanism.

Aggravation Example

It is my medical opinion that [Veteran's Name]'s pre-existing hypertension has been permanently aggravated beyond its natural progression by his service-connected anxiety disorder.

Records document baseline blood pressure of approximately 135/82 prior to the onset of anxiety symptoms in 2019. Following anxiety diagnosis and rating, blood pressure readings have consistently averaged 150/92 despite the addition of a second antihypertensive medication. The chronic stress response associated with anxiety disorders is well-established in medical literature as a contributing factor to sustained blood pressure elevation. This represents aggravation beyond the expected natural progression of hypertension.

What NOT to Do

Weak nexus letter (don't use):

"I have treated [Veteran] for knee pain. His knee problems could possibly be related to his time in the military. He reports that his knees hurt during service."

This example fails because it uses speculative language ("could possibly"), provides no records review, offers no medical rationale, and relies solely on the veteran's self-report without objective findings.

Getting a quality nexus letter requires preparation and knowing who to ask. Here's a practical approach:

1. Start with Your Treating Physician

Your best option is often a doctor who already knows your medical history. They can speak to the progression of your condition and have access to your records. When approaching them:

• Bring organized records including STRs, VA records, and any prior C&P reports
• Explain the VA's "at least as likely as not" standard
• Provide our Nexus Letter Template as a structural guide
• Offer to highlight relevant sections in the records to save their time

2. Conversation Starters for Reluctant Providers

Many doctors are unfamiliar with VA claims. Try these approaches:

• "I'm not asking you to guarantee anything—just whether it's 50% or more likely that my service caused this condition."
• "The VA needs a medical opinion connecting my [condition] to my service. Based on what you've seen in my records, would you be comfortable providing that opinion?"
• "I have a template that shows what format the VA prefers. Would you be willing to review it?"

3. Independent Medical Opinion (IMO) Services

If your treating physician can't or won't write a nexus letter, IMO services connect veterans with doctors who specialize in VA medical opinions. These providers:

• Understand VA evidentiary standards
• Know how to write opinions that address VA requirements
• Typically review records and conduct examinations (in-person or telehealth)

4. Telehealth Options

Many nexus letter providers now offer telehealth consultations. This expands your options beyond local providers and can be particularly helpful for:

• Veterans in rural areas
• Specialized conditions requiring specific expertise
• Cases requiring a fresh perspective after local providers declined

What to Bring to the Appointment

• Service treatment records (STRs)
• DD-214 or discharge paperwork showing MOS and service dates
• All VA medical records related to the condition
• Private treatment records
• Prior C&P exam reports (if any)
• Your personal statement describing how the condition affects you
• The Nexus Letter Template

Nexus letter costs vary significantly based on the provider, complexity of your condition, and whether records review and examination are included.

Typical Price Ranges

• Treating physician: $0 - $500 (some include it as part of regular care; others charge for the administrative time)
• Independent Medical Opinion services: $750 - $2,000 (includes records review and examination)
• Specialist opinions: $1,000 - $3,000+ (complex cases requiring subspecialty expertise)

Average Cost

Most veterans pay between $1,000 and $1,500 for a quality nexus letter from an IMO service. This typically includes records review, an examination (in-person or telehealth), and revisions if needed.

Factors Affecting Cost

• Volume of records: More records to review = higher cost
• Complexity: Conditions requiring multiple specialists or extensive literature review cost more
• In-person vs. telehealth: In-person examinations may cost more
• Provider credentials: Specialists typically charge more than general practitioners
• Rush fees: Expedited turnaround adds to the cost

Free and Low-Cost Options

• Treating physicians: Ask if they'll write one as part of your ongoing care
• VSO assistance: Some Veterans Service Organizations help coordinate medical evidence
• Academic medical centers: Some offer reduced rates for veterans
• VA examination: The C&P exam is free, though you can't direct the opinion

Note: Be cautious of very low-cost nexus letters. A $200 nexus letter that gets rejected costs more than a $1,200 letter that wins your claim.

The VA assigns "probative weight" to nexus letters based on their quality. Avoid these mistakes that reduce or eliminate your letter's value:

1. Speculative Language

Words like "may," "could," "possibly," and "might" indicate speculation rather than medical probability. The VA cannot grant benefits based on speculation. Use definitive language: "at least as likely as not," "more likely than not," or "is the result of."

2. Missing Rationale

A conclusion without explanation carries little weight. The VA wants to understand the medical reasoning, not just the bottom-line opinion. The letter must explain why the provider reached their conclusion, citing specific evidence and medical principles.

3. No Records Review Documentation

Letters stating "based on the veteran's report" without indicating records were reviewed are weaker than letters showing the provider examined objective evidence. Always list the specific records reviewed.

4. Wrong Provider Credentials

A nexus letter from an unqualified provider (non-medical professional, chiropractor for non-spine conditions) may be disregarded entirely. Ensure your provider meets the VA's definition of competent medical evidence.

5. Generic Templates Without Personalization

Letters that read like form letters with blanks filled in are less persuasive than individualized opinions. The letter should reference specific findings from your records, not generic statements that could apply to anyone.

6. Failing to Address Counterarguments

If a prior C&P examiner gave a negative opinion, the nexus letter should address why that opinion was incorrect or incomplete. Ignoring contradictory evidence weakens the letter's credibility.

7. No Clear Conclusion

Some letters discuss the veteran's condition at length but never clearly answer the nexus question. End with an unambiguous statement connecting the specific condition to service.

A denial doesn't mean your case is over. Many denials are overturned with better evidence or by correcting errors. Here's your path forward:

1. Request Your C-File

Your claims file contains the C&P examiner's opinion and the rater's reasoning. Understanding why you were denied tells you exactly what evidence to address. Request your C-file through VA.gov or submit a Privacy Act request.

2. Get an Independent Nexus Addressing the Denial

Once you know why you were denied, obtain a nexus letter that specifically addresses those reasons. If the C&P examiner said your condition wasn't related to service because there were no STR entries, your new nexus letter should explain why that gap doesn't break the chain—perhaps citing medical literature on delayed symptom onset.

3. File a Supplemental Claim

With new nexus evidence in hand, file VA Form 20-0995 (Supplemental Claim). The new nexus letter qualifies as "new and relevant evidence" to reopen your claim. There is no deadline for Supplemental Claims, though filing sooner protects potential effective dates.

4. Consider a Higher-Level Review

If you believe the VA made a clear error in evaluating existing evidence (rather than lacking evidence), a Higher-Level Review may be appropriate. This is reviewed by a senior rater who can overturn the decision without new evidence.

5. Board of Veterans' Appeals

For complex cases where the VA repeatedly ignores evidence or makes legal errors, the Board of Veterans' Appeals provides another avenue. This takes longer but offers review by Veterans Law Judges with more authority to correct persistent problems.

See our Supplemental Claim Playbook and Higher-Level Review Playbook for detailed guidance on each option.

Our nexus letter template gives your doctor a proven structure that meets VA requirements. It includes all five essential elements and uses language the VA expects to see.

Download Nexus Letter Template (PDF)

How to Use the Template

1. Don't submit it as-is: The template is a structural guide, not a fill-in-the-blank form. Your provider must personalize it with specific findings from your records.
2. Highlight relevant records: Before your appointment, mark the specific pages in your STRs and medical records that support your claim. This helps your provider reference them.
3. Discuss the rationale: The strongest part of any nexus letter is the medical reasoning. Talk through the "why" with your provider so they can articulate it clearly.
4. Review before finalizing: Check that the letter uses "at least as likely as not" language and includes a clear records review statement before your provider signs it.

Additional Resources

• Evidence Checklist Generator — Build a complete evidence list for your specific claim
• Secondary Conditions Finder — Identify secondary claims linked to your service-connected conditions
• Full Template Library — Lay statements, DBQ guides, and more
• C&P Exam Prep Playbook — Prepare for your Compensation & Pension examination