Complete Guide to Nexus Letters for VA Claims: Templates & Examples

A nexus letter can be the difference between a denied claim and receiving the VA disability benefits you've earned. This comprehensive guide explains what nexus letters are, why they're critical for VA claims, and how to obtain a strong medical nexus opinion that proves service connection.

What Is a Nexus Letter?

A nexus letter is a detailed medical opinion from a qualified healthcare provider that establishes a connection (or "nexus") between your current disability and your military service. The letter explains how and why your condition is related to service, using medical evidence and clinical reasoning.

Why Nexus Letters Are Critical for VA Claims

The VA requires three elements to grant service connection:

1. Current diagnosis – You have a medically diagnosed condition
2. In-service event – Something happened during service (injury, exposure, illness)
3. Medical nexus – A link connecting your current condition to the in-service event

A nexus letter provides element #3, which is often the missing piece in denied claims. Without a medical professional's opinion connecting your condition to service, the VA may deny your claim even if you have a current diagnosis and service records.

When You Need a Nexus Letter

You need a nexus letter when:

• Filing a direct service connection claim – Your condition was caused by service
• Filing a secondary service connection claim – Your condition was caused by an already service-connected disability
• Appealing a denied claim – The VA denied your claim for lack of service connection
• Increasing your rating – You're proving your condition has worsened
• No medical records exist – Service medical records don't document your condition

What Makes a Strong Nexus Letter?

An effective nexus letter must meet VA standards and contain specific medical language. Here's what the VA looks for:

Required Elements

A strong nexus letter includes:

1. Provider credentials – MD, DO, PhD, or other qualifying medical professional
2. Review of evidence – References to service records, medical records, and lay statements
3. Current diagnosis – Confirms your medical condition with diagnostic criteria
4. In-service event – Identifies what happened during service
5. Medical rationale – Explains how service caused or aggravated your condition
6. Nexus statement – Clear opinion using VA's preferred language
7. Research citations – Medical literature supporting the connection (optional but helpful)

The Critical Nexus Statement

The most important part is the nexus statement. Use this language:

Strong nexus statements:

• ✅ "It is at least as likely as not (≥ 50% probability) that the veteran's [condition] is related to military service."
• ✅ "In my medical opinion, it is more likely than not that [condition] was caused by [service event]."
• ✅ "The veteran's [condition] is at least as likely as not due to [service-connected condition]." (for secondary claims)

Weak statements to avoid:

• ❌ "It is possible the condition is related to service." (Too weak – implies less than 50% probability)
• ❌ "The condition could be service-connected." (Non-committal)
• ❌ "I believe the condition is related." (Opinion without medical basis)

The VA uses a 50% threshold for service connection. "At least as likely as not" means ≥ 50% probability, which meets the VA's standard.

How to Get a Nexus Letter

You have several options for obtaining a nexus letter:

1. VA Healthcare Provider (Free)

Pros:

• Free of charge
• Provider has access to all VA medical records
• Familiar with VA system

Cons:

• May be reluctant to provide nexus opinions
• Limited time for detailed letters
• Potential conflicts of interest

How to request: Ask your VA provider during an appointment if they can provide a nexus letter or medical opinion for your claim.

2. Private Healthcare Provider ($150-$500)

Pros:

• More willing to provide detailed opinions
• Can be specialists in your condition
• Independent from VA

Cons:

• Costs vary ($150-$500 or more)
• May not be familiar with VA requirements
• Need to provide all medical records

How to request: Schedule an appointment specifically for a nexus letter evaluation. Bring all medical and service records.

3. Independent Medical Opinion (IMO) Service ($750-$2,500)

Pros:

• Specialists in VA nexus letters
• Know exactly what VA requires
• Review all records thoroughly
• Often includes Disability Benefits Questionnaire (DBQ)

Cons:

• Expensive ($750-$2,500+ depending on complexity)
• Not an in-person evaluation (most are record reviews)

4. Compensation & Pension (C&P) Exam

The VA may order a C&P exam to evaluate your claim. While the examiner should provide a nexus opinion, C&P examiners often provide unfavorable opinions or fail to review all evidence.

Pro tip: Bring a private nexus letter to your C&P exam to supplement the examiner's opinion.

Nexus Letter Template Structure

Here's a template structure for an effective nexus letter:

[Provider Letterhead]
[Date]

To Whom It May Concern:

RE: Nexus Letter for [Veteran Name], [Last 4 of SSN]

I am writing to provide a medical opinion regarding the relationship 
between [Veteran Name]'s current diagnosis of [Condition] and their 
military service from [dates].

**Provider Credentials:**
I am a [specialty] with [X] years of experience treating [condition type]. 
I am board-certified in [specialty] and licensed in [state].

**Records Reviewed:**
I have reviewed the following records:
- DD Form 214 (Certificate of Release or Discharge)
- VA medical records from [dates]
- Private medical records from [providers/dates]
- Service treatment records from [dates]
- Lay statements from [veteran/spouse/others]

**Current Diagnosis:**
[Veteran Name] has been diagnosed with [Condition] per [DSM-5/ICD-10/
diagnostic criteria]. Symptoms include [list symptoms].

**In-Service Event:**
During military service, [Veteran Name] experienced [describe in-service 
event/injury/exposure]. This is documented in [service records/buddy 
statements/veteran statement].

**Medical Rationale:**
Based on my clinical experience and the medical literature, [condition] 
is commonly caused by [mechanism]. The veteran's [in-service event] 
directly caused/aggravated [condition] because [explain medical reasoning].

**Nexus Opinion:**
It is at least as likely as not (≥ 50% probability) that [Veteran Name]'s 
current diagnosis of [Condition] is related to their military service, 
specifically [in-service event].

Sincerely,

[Signature]
[Provider Name, Credentials]
[License Number]
[Contact Information]

Common Mistakes to Avoid

1. Using Weak Nexus Language

❌ Wrong: "It's possible the condition is related to service." ✅ Correct: "It is at least as likely as not that the condition is related to service."

Why it matters: "Possible" implies less than 50% probability, which doesn't meet VA's standard.

2. No Medical Rationale

❌ Wrong: "The veteran has PTSD from service." ✅ Correct: "The veteran's documented combat exposure in Iraq (2007-2008) directly caused PTSD per DSM-5 Criterion A (exposure to actual or threatened death). The veteran meets all diagnostic criteria including intrusive memories (Criterion B), avoidance (Criterion C), negative cognitions (Criterion D), and hyperarousal (Criterion E)."

Why it matters: The VA requires medical reasoning, not just conclusions.

3. Ignoring Contrary Evidence

❌ Wrong: Only citing evidence that supports service connection. ✅ Correct: "While the veteran smoked for 10 years post-service, the medical literature shows that hypertension caused by PTSD-related stress is independent of smoking status. The veteran's hypertension began 2 years before smoking cessation, supporting PTSD as the primary cause."

Why it matters: Addressing contrary evidence strengthens credibility.

4. Not Reviewing Records

❌ Wrong: Letter based only on veteran's verbal statement. ✅ Correct: "I reviewed 450 pages of service treatment records, 200 pages of VA medical records, and conducted a 90-minute clinical interview."

Why it matters: The VA wants evidence-based opinions, not just beliefs.

Secondary Service Connection Nexus Letters

Many veterans don't realize they can claim secondary conditions – disabilities caused by an already service-connected condition.

Common Secondary Connections

PTSD can cause:

• Sleep apnea (hyperarousal → fragmented sleep → OSA)
• Depression/anxiety (co-occurring mental health conditions)
• GERD (stress-induced acid reflux)
• Hypertension (chronic stress → high blood pressure)
• Erectile dysfunction (medication side effects + psychological factors)

Knee injury can cause:

• Hip pain (altered gait)
• Lower back pain (compensatory movement)
• Ankle problems (changed weight distribution)

Tinnitus can cause:

• Migraines (auditory stress)
• Sleep disturbance (inability to fall asleep)
• Depression (quality of life impact)

Secondary Nexus Letter Example

"It is at least as likely as not that the veteran's Major Depressive Disorder is secondary to his service-connected PTSD at 70%. PTSD and depression are highly comorbid conditions, with 50% of PTSD patients developing MDD (Flory & Yehuda, 2015). The veteran's PTSD symptoms directly contribute to his depressive symptoms by causing social isolation, sleep deprivation, and hopelessness about recovery. The temporal relationship is clear: PTSD diagnosis in 2010, MDD diagnosis in 2012."

How the VA Evaluates Nexus Letters

VA raters evaluate nexus letters based on:

1. Provider qualifications – Is the provider qualified to diagnose and treat this condition?
2. Thoroughness – Did the provider review all evidence?
3. Medical reasoning – Is the rationale scientifically sound?
4. Nexus strength – Does it meet the "at least as likely as not" standard?
5. Consistency – Does it contradict other medical evidence?

Pro tip: If the VA denies your claim despite a strong nexus letter, the denial should explain why the opinion was rejected. This gives you grounds for appeal.

Nexus Letters vs. DBQs

Nexus letters establish service connection (the link to service).

DBQs (Disability Benefits Questionnaires) establish severity (the rating percentage).

You often need both for a successful claim:

• Nexus letter proves the condition is service-connected
• DBQ documents the severity of symptoms for rating purposes

Cost-Benefit Analysis: Is a Nexus Letter Worth It?

Example:

• Private nexus letter cost: $500
• Potential 30% rating for sleep apnea: $552.47/month ($6,630/year)
• Retroactive back pay to claim filing date (12 months): $6,630
• Total first-year benefit: $13,260

Return on investment: 2,552% (not including lifetime monthly payments)

For most veterans, a quality nexus letter pays for itself within the first month of receiving benefits.

Frequently Asked Questions

Do I need a nexus letter for every condition?

No. You need a nexus letter when:

• Service records don't clearly document your condition
• The connection to service isn't obvious (e.g., secondary conditions)
• The VA previously denied your claim for lack of service connection

You generally don't need one if service records clearly document an injury and you've had continuous treatment since service.

Can I write my own nexus letter?

No. The VA requires a medical professional to provide nexus opinions. Lay statements (buddy letters, personal statements) can support your claim but cannot establish medical causation.

How long is a nexus letter valid?

Nexus letters don't expire, but older letters (>2 years) may be less persuasive if your condition has changed significantly. For rating increases or appeals, get an updated evaluation.

What if the VA rejects my nexus letter?

The VA must explain why they rejected the opinion. Common reasons:

• Provider not qualified
• Didn't review all evidence
• Reasoning not sound
• Contradicts other strong evidence

You can submit a stronger letter from a different provider or appeal the decision.

Can a nurse practitioner write a nexus letter?

Yes, but only for conditions within their scope of practice. For example:

• Mental health NPs can write for PTSD, depression, anxiety
• Family NPs can write for general medical conditions
• Specialized NPs can write for their specialty

For complex conditions, an MD or DO opinion carries more weight.

Using Your Nexus Letter

Once you have a strong nexus letter:

1. Submit with your VA claim – Include it with your initial application (VA Form 21-526EZ)
2. Upload to VA.gov – Add as supporting evidence in your online claim
3. Bring to C&P exam – Give a copy to the examiner (they should consider it)
4. Use for appeals – Submit with your Supplemental Claim or Higher-Level Review
5. Update regularly – If your condition worsens, get an updated letter for rating increases

Find Benefits You Qualify For

Once you establish service connection, use the Veterans Benefits Finder to discover all the federal and state benefits you're now eligible for. Many benefits require specific disability ratings or service-connected status—getting your conditions properly rated unlocks thousands in potential benefits.