How to Get a Nexus Letter in 7 Steps

Getting a nexus letter for VA disability feels way harder than it should. Many veterans hit the same wall over and over — primary doctors refuse to write one, VSOs offer vague advice, and private companies charge hundreds or even thousands of dollars without guaranteeing results.

That leaves a lot of vets stuck, frustrated, and unsure who to trust.

This guide breaks the process down step by step. You’ll learn when you actually need a nexus letter, how to organize your evidence, where to find reliable doctors who write them, and how to request one the right way.

We’ll also cover common mistakes to avoid so you don’t waste time or money — and so you can finally get the service connection you deserve.

Step 1: Determine if You Need a Medical Nexus Letter

Most primary service-connected conditions are easier to prove, but secondary conditions usually need a VA nexus letter.

The VA specifically looks for evidence that links a veteran’s current disability or current medical condition to their military service when evaluating disability claims. If they cannot determine that, they need a nexus letter.

Primary Conditions

Primary conditions are disabilities that started during service or were directly caused by military duty. These claims often already have strong evidence in service treatment records, so you don’t usually need a nexus letter to prove that.

A nexus letter helps most if:

• Your injury or illness wasn’t documented clearly in service

• Your symptoms didn’t start until after discharge but are still related

• A C&P examiner said there is no medical link

• Your condition isn’t presumptive (granted) under VA rules

Here's the good news — nexus letters are generally way easier to get for primary conditions because it's easier for your doctors to see that direct link.

Secondary Conditions

Secondary conditions are disabilities caused or worsened by another service-connected condition. This includes cases where one condition led to another as well as cases where your time in service aggravates a pre-existing condition.

Nexus letters for secondary claims are almost always essential for a few reasons:

• Alternative Causes: Many secondary conditions have other potential causes which need to be ruled out.

  Delayed Onset: Secondary conditions often appear years after service, so the connection isn’t obvious without documentation.

• C&P Denials: the VA heavily relies on Compensation & Pension exams, which frequently deny secondary claims

It can take a bit more time obtaining a nexus letter for secondary conditions can because you need the right doctor and a clear understanding of VA requirements.

Step 2: Create a Template & Clear Instructions

The first thing to do is create a custom nexus letter template for your condition. I’ve already created a detailed guide on the best nexus letter templates, so I won’t cover that here.

Next, you should prepare a one-page summary for your doctor that clearly outlines your case, including:

• Timeline of Your Condition: Create an exact timeline showing: time in service → first symptoms → diagnosis → treatments.

• Service Treatment Records (STRs): Highlight any complaints, injuries, or diagnoses during service that relate to your claim.

• VA & Civilian Medical Records: Show ongoing treatment and how your symptoms progressed over time.

• Buddy or Lay Statements: Include any statements from people who can corroborate in-service events or continuity of symptoms.

• Prior C&P Exam Reports: Note where the examiner may have misunderstood or overlooked evidence, so your doctor can address it directly.

The more research and preparation you do yourself, the better. Trust me, a small time investment now will save you both time and money later.

Step 3: Choose the Right Type of Doctor

Not every doctor is a good fit for writing a nexus letter. Choosing the right provider depends on your condition, the complexity of your claim, and your comfort level with their experience.

Primary Care Doctors

Most people start with their primary care provider, which works well if your case is straightforward:

Good when:

• You’ve had the same doctor for years: Doctors that know your medical history well may be more willing to write you a nexus letter.

• Simple Service Connections: Conditions with an obvious link to an existing disability, like combat related PTSD or Tinnitus.

Not good for:

• Complex Secondary Conditions: Claims needing expert reasoning, like PTSD → sleep apnea or chronic pain → depression.

• Rare or Highly Technical Conditions: Conditions like certain cancers, autoimmune diseases, or cardiac complications secondary to medications.

Regardless, your doctor can be a great resource for organizing your medical information and verifying your medical records.

Specialists

A nexus letter from a specialist is often essential for complex or secondary conditions. Specialists add value through:

• Expert knowledge: They understand your condition and can clearly explain how one issue caused or worsened another.

• Credibility with the VA: The VA gives more weight to opinions from doctors who specialize in the relevant field.

• Ability to address denials: Specialists can write detailed explanations to counter C&P exam findings or “no medical nexus” decisions.

While cost and finding the right provider can be challenges, a specialist’s input is often the key to getting your claim approved.

Nurse Practitioners

Nurse practitioners provide the lowest level of medical authority for nexus letters, so their opinions alone rarely sway the VA.

They often lack the specialized expertise needed to explain complex medical links.

Still, they can be valuable for support, especially if they’ve treated you over time and can verify your ongoing symptoms or treatment history.

Because they’re more accessible and affordable than specialists, their statements can serve as a helpful supplement to a primary nexus letter from a physician.

VA Doctors

To the frustration of veterans, VA doctors usually will not write a nexus letter. Ironically, they’ll treat you up just fine, but ask for a nexus letter and suddenly it’s classified information — go figure.

However, a VA doctor can still be useful for providing recommendations or detailed treatment notes. I’ll cover this more later in the article.

Paid Companies

In the vast majority of cases, paid companies should be a last resort.

While some veterans have received successful nexus letters through these services, it’s a large financial investment for inconsistent results at best.

I also recognize that many veterans have exhausted all other options and have no choice. For those people, I will cover best practices for finding a reputable company later in the article.

Step 4: Find a Doctor Who Will Write You a Nexus Letter

Finding a doctor who understands how to write a strong nexus letter can be the hardest part of the process.

It’s often a numbers game, and finding the right doctor can take time. Expect to contact at least 5-10 providers before landing on one who’s a good fit.

Start Locally

Begin by checking VA and community care options near you.

1. Go to VA.gov/find-locations.

2. Enter your city or ZIP code.

3. Under Facility Type, select VA Health or Community Care Providers.

4. Under Service Type, pick the specialty related to your claim (for example, psychology, orthopedics, or sleep medicine).

5. When you call, ask if they offer “record reviews” or “independent medical opinions”. Avoid saying “nexus letter” until you know they understand VA claims.

If they say yes, confirm whether the provider has written medical opinions for VA claims before.

Use Specialist Directories

If local options don’t pan out, search medical directories for specialists who perform Independent Medical Examinations (IMEs) or disability evaluations.

These terms are more widely recognized by doctors. Here are a few recommended places to search:

• Psychology Today: For mental health–related claims (search by specialty and add “VA” or “PTSD”).

• Zocdoc or Healthgrades: Use filters for your condition and location, then call or message offices about IMEs or record reviews.

• American Board of Independent Medical Examiners (ABIME): Find certified IME doctors by state.

• SleepFoundation.org’s provider directory: Ideal for sleep apnea or respiratory-related claims.

When using Google, try searches like:

• Independent medical opinion + [city] + [specialty]

• IME for Veterans + [State]

Ask Veteran Service Organizations (VSOs)

VSOs can’t write nexus letters, but they often maintain lists of trusted providers who can.
Visit VA.gov/get-help-from-accredited-representative and contact local chapters of groups like the American Legion, DAV, or VFW.
Ask them directly:

“Do you have a list of doctors familiar with writing independent medical opinions or nexus letters for VA claims?”

They can sometimes point you toward specialists who’ve successfully helped other veterans.

Explore Trusted Paid Options

If you can’t find a local or VSO-recommended doctor, several private services specialize in nexus letters for veterans. Prices vary, so verify credibility before paying.

What to look for:

• Doctor’s full name, credentials, and specialty listed

• References to independent medical opinions or evidence-based rationale

• Record review included (not pre-written templates)

Example vetting email to send before you buy:

Subject: Quick Questions About Your Nexus Letter Process

Hi [Company Name] Team,
I’m a veteran comparing providers for an independent medical opinion (nexus letter). Before moving forward, could you clarify a few quick points?

• Is the letter custom-written after reviewing my medical/service records?

• Do your doctors use VA language like “at least as likely as not”?

• What’s the typical turnaround time?

• Will I be able to speak directly with the doctor?

• Is pricing flat-rate or based on case complexity?

Thanks — I appreciate your time.
[Your Name]

Step 5: Ask Your Doctor for a Nexus Letter the Right Way

Veterans have more control over whether a doctor agrees to write a nexus letter than they might think. Here are the practical steps you can take.

Prepare Your Outreach Pitch

The key to a good outreach pitch is to frame your request as asking for the doctor’s professional opinion, not a personal favor.

When providers see it as a medical review within their expertise rather than an extra task, they’re more open and confident about helping.

Example pitch:

Hi Dr. [Name], My name is [Veteran Name]. I served in the [Branch] from [Years]. I’m hoping you can review my records and provide a medical opinion about whether my [condition] is related to my service.

I’ve attached a one-page summary, my service records, and relevant treatment notes. I can also provide a short template to make formatting easier.

Please let me know if you’re open to reviewing them. Thank you for your time and consideration, [Your Name] [Phone/Email]

Tip: Attach only what’s necessary for a first review. Overloading them with hundreds of pages right away can discourage participation.

Call or Meet in Person

Once you have your outreach pitch, the next step is to follow up with a phone call or in-person visit.

• Be polite, direct, and professional — think of it as a consultation, not a plea.

• Briefly explain why you believe your condition is service-connected (for example, “I did some research and came across these studies for my condition”).

• Offer to pay for their time if appropriate - Might be necessary since most doctors want to be paid for their time.

Consistency and courtesy go a long way. A short, confident explanation often earns more respect than a long emotional appeal.

Handle Objections

Many doctors may hesitate to write a nexus letter, often because of its complexity and their lack of VA knowledge. Here are a few common responses you might get and how to handle them professionally.

Example 1: “I don’t write nexus letters and have no experience”

You can respond with:

“I understand completely. Would you be open to doing a record review or providing a medical opinion instead?”

This shifts the focus from “nexus letter” (which some doctors associate with legal paperwork) to something they’re more comfortable with — a clinical review.

Example 2: “I’m not sure your condition is service connected”

You can say:

“That’s understandable. I have a short summary showing when my symptoms started and how they’ve progressed if you’d like to take a look.”

Offering evidence calmly shows you’re informed and gives them a chance to see your reasoning without pressure.

Example 3: “That’s a VA issue.”

You can clarify:

“I totally get that. I’m not asking for a legal statement—just your medical opinion on whether my service could have caused or aggravated the condition.”

This helps them see their role as purely medical, not administrative, which often puts them at ease.

Step 6: Strengthen Your Nexus Letter

Even with the right doctor, the quality of your nexus letter can make or break your VA claim.

These quick tips will help ensure your letter is as strong and credible as possible.

1. Be persistent: It may take several tries to find a doctor willing to review your records. Don’t get discouraged — persistence is normal and often what separates approved claims from denied ones.

2. Research real examples: Read examples of strong and weak nexus letters so you understand the tone, structure, and detail level that persuades VA reviewers. This helps you recognize what quality looks like.

3. Avoid boilerplate templates: Every case is unique. Doctors who use one-size-fits-all templates can weaken your claim because VA reviewers recognize generic or copied language immediately.

4. Keep copies of everything: Save all communications, drafts, and evidence you send or receive. Organized documentation makes follow-ups easier and protects you if anything goes missing in the VA system.

The main takeaway for veterans should be to do the most work you can possible. This will help you get the best nexus letter for the lowest cost.

Step 7: Take Alternative Actions if You Fail

If you’ve truly followed all of the steps in this guide thoroughly, it is highly unlikely you will reach this point.

But if you truly can’t find a doctor willing to write a nexus letter, here’s what you can do:

• Strengthen your medical evidence: Make sure your treatment records and service history show a consistent continuity of symptoms over time.

• Submit a Supplemental Claim: If you were denied for “no nexus,” add new and relevant evidence like medical research, buddy statements, or updated medical notes.

• Consider lower-cost options: Ask providers if they offer record reviews or short medical opinions instead of full letters.

• Use proper phrasing: Even a brief note stating “at least as likely as not” can strengthen your file.

Persistence pays off — most veterans need to contact several providers before finding one who’s both willing and qualified.

Getting a Winning Nexus Letter Takes Time

Getting a strong nexus letter takes time, patience, and organization — but it’s absolutely worth it.

The process itself is straightforward: gather your evidence, find the right specialist, and make a clear, professional request.

The hardest part is staying persistent long enough to find a doctor who understands VA claims. Putting in that extra effort now can save you years of frustration and denials later.

A well-written, evidence-based nexus letter is often the difference between a denied claim and the benefits you’ve earned through your service.

FAQ

• How much do doctors charge for nexus letters?

  It depends. Your primary care doctor or nurse practitioner may be willing to write a nexus letter for free or for a small fee, especially if you’re already their patient. Specialists, on the other hand, often charge anywhere from $200 to $800, depending on the complexity of the case. Some private companies and expert medical reviewers can charge $500 to $2,000 or more for detailed independent medical opinions. Remember — a higher cost doesn’t always mean higher quality, so it’s important to look for experience and credibility rather than just price

• Do C&P doctors write nexus letters?

  C&P exam doctors technically can write nexus opinions, and their opinions hold equal weight to those from your private doctor. However, you can’t hire or request them to write one in your favor — their job is to give an independent opinion for the VA. If a C&P examiner’s opinion goes against your claim, you’ll often need to get your own nexus letter from a qualified medical professional to counter or clarify their findings.

• Where can I get a nexus letter?

  You can get a nexus letter from a VA doctor, community care provider, private specialist, VSO-recommended doctor, or an independent medical company that offers IMEs. All of these options can work in some cases but not others — it depends on the doctor’s experience, how well they explain the medical link, and how strong your evidence is.

• What is the best type of doctor to write a nexus letter?

  The best doctor for a nexus letter is usually a specialist in the condition you’re claiming — like a sleep specialist for sleep apnea or a psychologist for PTSD — since the VA gives their opinions more weight. However, if your claim involves a straightforward primary condition such as a knee or back injury that’s clearly linked to service, your primary care doctor can often provide a strong nexus letter without needing a specialist. It really depends on how complex the medical link is.

• Do VA doctors write nexus letters?

  VA doctors can write nexus letters, but most won’t due to VA policy and workload limits. They’re often discouraged from giving opinions that could affect claim outcomes. Some may still provide supporting notes in your records, but if you need a formal nexus letter, it’s usually better to go through a private or community care doctor instead.

Do You Need a Nexus Letter for Secondary Conditions?

Secondary conditions are one of the most confusing parts of the VA disability process. The standards for proving them are inconsistent, and veterans get denied all the time even when the medical connection seems obvious.

You submit evidence, explain your symptoms, and still end up wondering why the VA did not recognize the link.

Nexus letters for secondary conditions are often the missing piece that shows the VA how a service-connected disability caused or aggravated another condition.

While not all secondary claims require a nexus letter, a strong one can be the difference between approval and denial.

This guide explains when you need a nexus letter for a secondary condition, which conditions typically require one, and includes a sample letter to help you strengthen your claim and get approved.

What is a Secondary Service Connection?

A secondary service connection basically means the VA has already recognized one condition as service-related, and that condition causes another issue or makes your intial condition worse.

There are two types of secondary service connections:

1. Secondary Causation: The new condition was directly caused by the service-connected one.

   Example: Veteran has PTSD that causes sleep apnea.

2. Secondary Aggravation: A non-service-connected condition gets worse because of the service-connected one.

   Example: Veteran has pre-existing PTSD which worsened after service.

To qualify for a secondary service connection, you need a VA-rated primary condition first. It also helps if your secondary condition develops after your primary condition.

Examples of Secondary Connections

Below is a list of the most common secondary conditions that are approved. It doesn’t include every possibility, just the ones most likely to be granted.

• PTSD → Sleep Apnea

• Hypertension → Sleep Apnea

• Tinnitus→ Sleep Apnea

• Depression → Sleep Apnea

• PTSD → Hypertension

• Rhinitus → Sleep Apnea

• Gerd → Sleep Apnea

• Traumatic Brain Injury → Chronic Migraine

You'll notice this list includes only official diagnoses, not general symptoms. For secondary conditions, you cannot get a nexus letter for 'back pain' or 'knee pain'. Instead, you a formal diagnosis to connect those symptoms to a condition.

Do You Need a Nexus Letter for Secondary Conditions?

By nature, most secondary conditions require a nexus letter because they aren’t documented during service, often develop years later, and may have other possible causes.

However, the stage of your VA claim when you get one matters. These are the points in the process when you should consider it.

Your C&P Exam Was Unfavorable

If your Compensation & Pension (C&P) exam didn’t support your claim, you need a nexus letter. The VA heavily relies on these for establishing service connection.

Example: Derrick filed a claim for migraines secondary to a traumatic brain injury, but the VA denied it after a negative C&P exam.

In this case, a nexus letter could challenge this and offer medical evidence linking his migraines to the TBI.

Your Secondary Condition Isn’t Clearly Documented

Secondary conditions often don’t appear during service; symptoms can develop years later.

Example: John has a 50% rating for PTSD and develops sleep apnea two years later. His records don’t show any sleep apnea symptoms, so he needs a PTSD nexus letter explaining how it contributed to his sleep apnea.

When symptoms develop years later, the VA needs proof that your condition isn’t caused by external circumstances.

There’s More Than One Possible Cause

Some conditions, like sleep apnea, have many possible causes that aren’t related to your service. Others, like migraines, usually have only a few.

Either way, you should know the potential causes for your condition so your doctor can rule them out in the nexus letter

Example: Maria has PTSD and later develops sleep apnea. Her doctor rules out lifestyle factors such age, smoking, alcohol, etc.

Ruling out other possible causes helps show the VA that your condition developed because of your service, not from unrelated factors.

What Do You Need to Prove Secondary Connection?

To prove a secondary service connection, there are a few key things to understand. Pay close attention to this section, since many veterans overlook these important details.

Diagnosis from a Specialist

The first step in proving a secondary service connection is obtaining a clear diagnosis from a qualified medical professional.

1. Get a formal diagnosis from a specialist with expertise in the condition.

2. Provide the date of diagnosis and method used.

3. Include the credentials of the specialist.

A proper diagnosis lays the foundation for your claim and ensures the VA recognizes the condition as legitimate.

Clear Timeline of Symptoms

Show when your symptoms began and how they developed over time.

1. Record onset and progression of your secondary condition.

2. Include medical documentation of symptoms.

3. Explain how the condition has impacted your life in measurable terms.

If medical documentation is limited, buddy and lay statements can help establish your symptom timeline.

Medical Evidence or Rationale Linking the Conditions

Provide medical support explaining why the secondary condition is connected to your service-connected condition.

Good examples include:

1. Medical literature showing the conditions are related

2. Studies or clinical guidelines supporting the link

3. Other medical reasoning connecting the two conditions

Citing credible studies or expert reasoning—for example, research showing a correlation between PTSD-related weight gain and sleep apnea—makes your nexus argument stronger and more credible to the VA.

Nexus Letter for Secondary Condition Example

This is a nexus letter example presents a fictional case of a veteran whose PTSD treatment with certain medications contributed to weight gain, resulting in obstructive sleep apnea (OSA).

Dr. Sarah Thompson, MD – Board-Certified Sleep Specialist
123 Health Way • City, State, ZIP
Phone: (555) 987-6543
Date: October 17, 2025

To Whom It May Concern:

I have evaluated and treated Sergeant First Class Michael Thompson for obstructive sleep apnea (OSA), which developed secondary to service-connected Post-Traumatic Stress Disorder (PTSD). I am a board-certified sleep specialist with over 12 years of experience diagnosing and managing sleep disorders.

Mr. Thompson’s OSA diagnosis was confirmed using a polysomnography sleep study and documented in his medical records from the Thompson Sleep Center. His symptoms include loud snoring, daytime fatigue, morning headaches, and frequent nighttime awakenings.

Annotation: Listing objective diagnostic criteria and specific test results increases the credibility of the medical opinion.

Mr. Thompson’s PTSD diagnosis was confirmed using DSM-5 criteria and documented on VA Form 21-0960P-3. He has been treated with multiple medications for PTSD, including those known to contribute to weight gain. This weight gain is a medically recognized risk factor for obstructive sleep apnea and is clearly documented in his treatment and clinic notes between 2010–2025.

Annotation: Linking medication side effects to secondary medical conditions establishes a plausible causal pathway.

I reviewed Mr. Thompson’s complete C-file, service treatment records, VA mental health evaluations, and sleep clinic notes. The onset of OSA occurred after sustained PTSD treatment and documented weight gain, creating a clear temporal relationship between his service-connected PTSD, its treatment, and the development of OSA.

Annotation: Providing a timeline with documentation strengthens the nexus by showing chronological causation.

Other potential causes for OSA were carefully evaluated and ruled out. Mr. Thompson has no documented history of congenital airway abnormalities, chronic respiratory disease, or non-service-related factors sufficient to cause OSA. His BMI increase is directly associated with PTSD medication management.

Annotation: Eliminating alternative causes ensures the “at least as likely as not” standard is satisfied.

Based on my review and clinical evaluation, it is my professional opinion that Sergeant First Class Michael Thompson’s obstructive sleep apnea is at least as likely as not (50% or greater probability) caused or aggravated by his service-connected PTSD and related weight gain from PTSD medications.

This opinion is rendered using the VA’s “at least as likely as not” standard and is supported by objective diagnostic testing, documented weight changes, clinical evaluation, and the absence of alternative explanations.

Sincerely,
[Signature]
Dr. Sarah Thompson, MD
Board-Certified Sleep Specialist

Final Thoughts on Nexus Letters for Secondary Conditions

Understanding how nexus letters work for secondary conditions gives veterans a clear path to strengthening their VA claim.

A well-written nexus letter links your service-connected disability to a new or aggravated condition and provides the medical proof the VA needs to grant approval.

Once you know when you need one, the next step is learning how to get a nexus letter the right way. With the right doctor, a clear diagnosis, and strong medical reasoning, you can build powerful evidence that greatly improves your chances of receiving the benefits you’ve earned

FAQ

• Is a nexus letter required for secondary conditions?

  Most of the time, you’ll need a nexus letter for secondary conditions. If your C&P exam was unfavorable or the medical connection between your conditions is weak, a nexus letter is almost always required

• Do I need a nexus letter for sleep apnea secondary to PTSD?

  For secondary conditions like sleep apnea linked to PTSD, the connection is usually not strong enough for the VA to grant benefits automatically. In these cases, you almost always need a nexus letter to make your claim

• How to prove secondary service connection?

  To prove a secondary connection, you need to show that your secondary condition developed as a result of your primary service-connected condition. This usually involves documenting a clear symptom timeline, ruling out other possible causes, and providing a medical explanation—often through a nexus letter—that links the two conditions

Nexus Letters for PTSD: Most Veterans Are Doing It Wrong

There’s no shortage of confusing information about nexus letters for PTSD. Many veterans do everything right — they research, find a doctor, gather evidence, wait months for a decision — only to get denied. Meanwhile, others seem to get high PTSD ratings without a letter at all.

As a veteran who’s been through the VA claim process myself, I get it. That’s why I made this guide: a clear, no-fluff breakdown of how to get a PTSD nexus letter that actually works.

You’ll learn when you really need one, where to get it, and what to include so your claim stands the best chance of approval.

Do I Need a PTSD Nexus Letter?

You may need a nexus letter for PTSD for two main reasons: an unfavorable C&P exam or a lack of evidence linking your condition to service.

Veterans generally fall into two groups — those with combat-related trauma and those with non-combat-related trauma. Nexus letters are usually more important for non-combat cases, but read this section carefully to see where you fit.

Even if you’re already service-connected for PTSD, you can often get a nexus letter for secondary conditions. This article, however, will focus on direct connections.

Combat-Related Causes (no nexus needed)

Combat-related PTSD is post-traumatic stress that develops from exposure to combat situations. The most common ones include:

• Firefights

• Ambushes

• IED or blast injuries

• Witnessing casualties within your unit

The VA assumes these events are traumatic, so you typically don't need a nexus letter. The exception? If your symptoms showed up more than a year later. In those cases, you might need a nexus demonstrating delayed onset of symptoms.

Non-Combat-Related Causes (nexus needed)

While not as common, plenty of you develop PTSD from non-combat events during service. These experiences include:

• Training accidents

• Vehicle or aircraft crashes

• Base assaults

• Military sexual trauma (MST)

These incidents can be just as brutal as combat trauma — especially when they involve unexpected deaths or suicides of fellow service members.

The problem? The VA doesn't automatically assume these are linked to PTSD, so you need a nexus letter establishing that connection.

Who Should Write a Nexus Letter for PTSD?

In most cases, your nexus letter needs to come from a specialist, not your primary care provider. They typically don't have the specialized training to provide the detailed VA-approved medical opinion you need.

What a PCP can do, and what I recommend, is gather a detailed history of your symptoms and medical background, as this will be important to reference in the letter.

Psychologist/Psychiatrist (Best)

The best option for a PTSD nexus letter is a psychologist or psychiatrist. These specialists know how to evaluate trauma-related conditions and understand how PTSD develops over time. Their opinion will carry the most weight with the VA.

While scheduling or cost could be hurdles, their expertise makes their evaluation far more effective for supporting your claim.

Many can also complete DBQs, which help document that the in-service event actually happened (more on that later).

Therapist (Decent)

If you can't get a letter from a psychologist or psychiatrist, a licensed therapist or counselor can be a solid backup — especially if you've been seeing them consistently over the years.

They can provide insight into your long-term symptoms, treatment progress, and how PTSD has messed with your daily life.

While their nexus letter might carry slightly less weight, their firsthand knowledge of your condition can still make a real difference in your claim.

What Should the Nexus Letter Include?

Before you ask a doctor to write your letter, you need to be deeply familiar with what the VA is looking for.

Give your doctor this checklist before they write it, and review the letter carefully yourself before submitting it.

DSM-5 PTSD Diagnosis from a Specialist

For PTSD cases, the VA only accepts diagnoses made by a qualified health professionals using DSM-5 criteria.

Your nexus letter must include:

• The diagnosis from a Psychologist or Psychiatrist

• A reference to DSM-5 in the letter

• Approximate date of diagnosis

Luckily, Psychologists and Psychiatrists are trained to diagnoses PTSD this way, so it should be straightforward.

Proof of the In-Service Event

The VA must see clear documentation that the traumatic event actually occurred during service — especially for non-combat cases, which often go unrecorded.

Examples of acceptable evidence include:

• Service treatment records documenting injuries from a training accident

• Official reports of a vehicle or aircraft crash

• Unit logs showing exposure to base assaults or other incidents

• Personnel records indicating behavioral changes or performance drops

If documentation is limited, buddy statements can help fill the gaps.

These are statements from fellow service members, friends, or family who can confirm the event or describe how your behavior changed after it.

Documentation of Symptom Timeline

When preparing your nexus letter, be clear and specific about your symptom history. The VA looks for consistency over time — not short spikes that disappear. Use this checklist to organize your information:

• When symptoms began: Ideally within one year of discharge. If onset occurred later, your doctor must explain why and how this delayed onset developed.

• Severity: Describe how symptoms impacted your daily functioning (sleep, work, relationships).

• Progression: Note how symptoms worsened or changed over time, supported by medical or therapy records.

If your service records don’t fully capture your timeline, buddy or lay statements can fill those gaps.

These statements serve as credible secondary evidence showing the continuity of your symptoms after service.

Rule Out Alternative Causes

This is where many PTSD nexus letters fall short. The provider must explain why your PTSD isn’t caused by something else — like preexisting conditions or post-service events.

The letter should:

• Acknowledge any prior medical or mental health history

• Explain why those earlier issues did not cause or contribute to current PTSD

• Emphasize how military service directly worsened or triggered symptoms

Example:

“While the veteran experienced mild anxiety before enlistment, the frequency and intensity of night terrors increased dramatically following the 2008 blast exposure, indicating aggravation by military service.”

Doctors often forget to include this reasoning, and the VA assumes another cause — leading to a denial.

Medical Rationale

This is the most important part of the nexus letter — the medical logic connecting your PTSD to your service.

The provider must explicitly write:

“It is at least as likely as not (50% or greater probability) that the veteran’s PTSD was caused by, or aggravated by, their military service.”

That single sentence carries enormous legal weight.
Without it, the VA can’t legally grant service connection — no matter how strong the rest of your evidence is.

To make it stronger, apply the “1:1 rule”: Every factual statement in the letter should be backed by a piece of supporting evidence — a record, date, or observed symptom

How to Get a Nexus Letter for PTSD

Finding the right doctor to write your letter is crucial, and is something that should not be rushed.

In many cases, it’s a numbers game. You might get some rejections initially, but it's absolutely worth the time to find a quality one.

Step 1: Start with Free Options

Begin at your local VA medical center. VA doctors rarely write nexus letters, but they can still point you towards qualified providers.

When you call or visit, ask for a social worker or mental health case manager and explain that you're looking for community providers who handle VA disability evaluations.

Pro tip: You're more likely to succeed if you phrase it as a "medical opinion connecting your condition to PTSD" instead of a "nexus letter". People often get confused by that term and might not want to deal with it.

Step 2: Check Local Directories

If the VA can’t help, search Psychology Today or your state licensing board for providers specializing in PTSD, veterans, or forensic evaluations.

On Psychology Today:
Get Help → Talk to Someone → Find a Psychiatrist/Psychologist, then search your city or state.

Prefer profiles with:

• MD/DO (Psychiatrists) or PhD/PsyD (Psychologists)

• Mentions of PTSD, veterans/military, or disability evaluations/IME reports

Forensic psychologists are often best — they’re familiar with legal-style documentation like nexus letters.

Step 3: Reach Out to VSOs

Veteran Service Organizations (VSOs) often maintain lists of trusted providers who understand VA standards.

Try:

• Disabled American Veterans (DAV)

• Veterans of Foreign Wars (VFW)

• American Legion

A quick call can get you referrals to doctors experienced in VA evaluations.

Step 4: Paid Companies (last resort)

If you can’t find a local provider, some companies specialize in nexus letters — but quality varies dramatically.

Before paying, make sure to:

• Verify credentials: Get the full name, license number, and specialty of the letter writer.

• Review sample quality: Letters should include detailed reasoning, not generic statements.

• Check reviews carefully: Use veteran forums, Trustpilot, or Google; watch for fake 5-star reviews or “guaranteed approval” claims.

A good company can save you time, a bad one can waste money and hurt your claim.

Step 5: Provide a Template or Example

Doctors often decline nexus letters because they’re complex and time-consuming. Writing a template is the single most important thing you can do to increase your chances of success.

Doing your own research not only takes some stress off your doctor's end, but also shows the VA your initiative and effort — which they love.

The template should include:

• Relevancy of your medical information

• VA specific language

• How to phrase their reasoning

Keep it simple — you're not telling them what to write, just giving them the format that the VA recognizes.

For a more detailed explanation, learn how to get a nexus letter step by step to make sure your evidence meets VA standards

PTSD Nexus Letter Example

This is an nexus letter example presents a fictional case of a veteran who experienced a serious training accident during basic training.

In this scenario, the veteran witnessed a live grenade malfunction, resulting in severe injuries to fellow trainees.

Dr. Jane Smith, PsyD – Licensed Psychologist
123 Main Street • City, State, ZIP
Phone: (555) 123-4567
Date: October 11, 2025

To Whom It May Concern:

I have evaluated and treated Sergeant First Class Michael Thompson for Post-Traumatic Stress Disorder (PTSD). I am a licensed psychologist with over 15 years of experience in trauma and stressor-related disorders.

Mr. Thompson’s PTSD diagnosis was confirmed using DSM-5 diagnostic criteria and documented on VA Form 21-0960P-3 (PTSD Disability Benefits Questionnaire). His symptoms include intrusive nightmares, avoidance behaviors, hypervigilance, irritability, and persistent negative mood and cognition.

Annotation: Listing symptoms directly from DSM-5 improves credibility and shows diagnostic alignment.

During basic training in 2008, Mr. Thompson was exposed to a live grenade malfunction during a supervised exercise. Several trainees sustained severe injuries, and he directly witnessed the event. This incident is recorded in his service treatment records (STRs) and supported by two buddy statements (VA Form 21-10210) submitted with his claim.

Annotation: Adding exact forms and evidence types signals strong documentary support.

Within weeks of the incident, he began experiencing nightmares related to the explosion, exaggerated startle response, and avoidance of training environments. These symptoms were noted in mental health clinic notes from Fort Benning (June 2008) and have persisted since that time.

Annotation: Linking symptom onset to dated records builds a clear nexus timeline.

I reviewed his entire C-file, service treatment records, prior VA mental health evaluations, and therapy progress notes (2020–2025). The continuity of symptoms from service to present day demonstrates a direct and ongoing connection to the in-service trauma.

Other potential causes for his symptoms were carefully ruled out. He has no documented pre-service psychiatric history, no traumatic brain injury, and no non-service trauma that could explain his condition. He also denies substance abuse or other lifestyle factors that might contribute to his PTSD.

Annotation: Eliminating other possible causes strengthens the “at least as likely as not” standard.

Based on my review and clinical evaluation, it is my professional opinion that Sergeant First Class Michael Thompson’s PTSD is at least as likely as not (50% or greater probability) caused by or aggravated by his military service, specifically the 2008 live-grenade training accident.

This opinion is rendered using the VA’s “at least as likely as not” evidentiary standard and is supported by objective documentation, consistent symptom presentation, and the absence of alternative explanations.

Annotation: Restating the VA standard verbatim ensures the letter meets adjudication requirements.

Sincerely,
[Signature]
Dr. Jane Smith, PsyD
Licensed Psychologist

This example is longer than what most veterans expect, but that’s intentional — the VA looks for detailed, well-supported letters that clearly connect your condition to your service.

This sample is for educational purposes only and should not be used as an official medical or legal document.

Final Thoughts on PTSD Nexus Letters

Navigating a PTSD claim with the VA can feel overwhelming, but a well-prepared nexus letter can make all the difference.

Whether you’re dealing with a non-combat trauma, a secondary PTSD claim, or an unfavorable C&P exam, the right letter connects your condition directly to your service and strengthens your case.

By understanding what the VA expects, finding the right provider, and ensuring your letter includes clear medical reasoning, you can give your claim the best chance of success.

Remember, a nexus letter is not just a form — it’s the key piece of evidence that turns your service and experiences into a compelling, service-connected claim

FAQ

• Do I need a nexus letter for a higher PTSD rating?

  You can get a higher VA rating for PTSD if your symptoms have worsened or if you are claiming that your PTSD caused another condition. Secondary conditions can include hypertension, sleep apnea, or migraines. In both cases, a nexus letter is needed to show the connection to your service-related PTSD

• How do I get a 70% PTSD rating?

  A 70% PTSD rating generally means your condition causes occupational and social impairment with deficiencies in most areas. This can include trouble completing tasks at work, difficulty maintaining relationships, periods of near-continuous depression or anxiety, and trouble handling stress. You might also experience withdrawal from family or friends, flattened affect, or occasional suicidal thoughts. The key is that your symptoms seriously disrupt most areas of your life, even if they aren’t constant

• Why do PTSD claims get denied?

  Denials usually happen if another condition or life event is seen as the main cause of symptoms, or if a C&P exam is unfavorable. A strong nexus letter and supporting documentation are usually the key to avoiding these issues

• What are two list 3 criteria that must be present for a diagnosis of PTSD?

  PTSD is diagnosed when a veteran has been exposed to a traumatic event and experiences symptoms like intrusive memories, avoidance, negative mood changes, or hyperarousal. These symptoms must last more than a month and cause significant problems in work, relationships, or daily life

Nexus Letter Examples: Best Template, Example Texts, & More

There's absolutely no shortage of nexus letter templates online — trust me, I've seen them all. Way too many veterans just download these fill-in-the-blank examples and hand them straight to their doctor without customizing them for their unique situation.

The result? The VA denies claims left and right that rely on these generic templates they've seen hundreds of times.

Writing a basic template is the easy part. The hard part is customizing it so your doctor knows exactly what to include and the right way to phrase it.

This guide provides a nexus letter template designed to far surpass generic examples, along with expert tips on customizing it specifically for your condition.

Why Most Nexus Letter Templates Don’t Work

The problem with basic nexus letter templates is that they oversimplify the complexity of individual cases.

Pre-Written Examples Mislead Your Doctor

Many prewritten nexus letter templates make it way too easy for a doctor to just fill in the blanks rather than analyze your unique case in detail.

• Bad: "This veteran's back pain is at least as likely as not due to military service."

• Good: This veteran’s chronic lower back pain began during active duty in June 2008 after repeated heavy lifting, with no prior history of back problems. Medical records confirm symptom onset during 2008–2009 while in service. Based on this evidence, it is at least as likely as not that the condition is related to military service

Most doctors have limited experience with nexus letters. A good nexus letter template gives the doctor a more detailed understanding of what evidence and reasoning is needed for your case.

One Template Won’t Fit Every Case

Every veteran’s case is different — and so is the nexus letter they need. Generic templates can’t account for your specific condition or the type of service connection you’re claiming.

You need a custom template for your doctor because:

• Different connections need different reasoning. Secondary conditions often require more detailed medical evidence than templates suggest.

• Each condition follows unique criteria. The VA rates back pain, tinnitus, PTSD, and sleep apnea using very different standards.

• Your service history changes the story. The link between your symptoms and duties (combat, lifting, noise exposure, etc.) must be clearly shown.

• Evidence must be personalized. What proves one veteran’s GERD claim might not apply to another’s hypertension.

• Templates lead to vague conclusions. Without tailored reasoning, your doctor may miss the details the VA relies on to approve service connection.

Our goal in this article is to show you how to write your own nexus letter template so you can get the evidence you need to win your case.

Nexus Letter Formatting Essentials

A Nexus letter represents a doctors professional opinion that links your specific condition to your time in military. Here is how the basic format flows:

1. Header and Date: Doctor’s letterhead, address, and date.

2. Veteran Information: Veteran’s name and identifying info (no SSN or full DOB — usually last four digits or claim number).

3. Introduction / Credentials: Doctor introduces themselves, their specialty, and their clinical relationship with the veteran.

4. Medical Summary and Diagnosis

   Overview of the veteran’s condition, when it began, relevant medical history.

5. Rationale and Evidence Review

   Discussion of records, symptoms, and medical reasoning that links the condition to service.

6. Medical Opinion Statement (Nexus Statement)

   The formal conclusion using VA language like: “It is at least as likely as not (50% probability or greater) that the veteran’s condition is related to military service.”

7. Signature and Contact Information

   Doctor’s signature, printed name, credentials, and contact info.

We cover all the basic essentials of nexus letters in our guide to VA nexus letters, so check it out if you want the full breakdown.

Next, we’ll look at strong examples for each section of a nexus letter.

Nexus Letter Example Sections

Knowing what belongs in a nexus letter isn’t the same as using it correctly. Applying the elements properly is what makes the letter effective for a VA claim.

This can also help you later when you meet with your doctor because you can show exactly what the VA looks for in a nexus letter.

Proper Formatting

The nexus letter should be professionally structured, including headers, dates, reference information, the veteran’s name, and the doctor’s signature. Clear formatting ensures the VA can easily read and process the letter.

Bad Example:

“To whom it may concern, I think this veteran’s back pain is related to service. Signed, Dr. X.”

• Lacks headers, dates, veteran details, and context.

Good Example:

Header: Dr. Jane Smith, MD – Orthopedic Specialist
Date: October 10, 2025
Patient: John Doe, DOB 01/01/1980, SSN XXX-XX-XXXX

This letter provides a medical opinion regarding Mr. Doe’s chronic lower back pain and its connection to military service.
Signature: Dr. Jane Smith, MD

Doctor’s Qualifications and Medical Specialty

The doctor must clearly state their credentials and area of expertise to establish authority and credibility in the VA claim.

Bad Example:

“I am a doctor and have seen the veteran in my office.”

Good Example:

“I am Dr. Jane Smith, MD, a board-certified orthopedic surgeon with 15 years of experience treating musculoskeletal injuries. I have evaluated Mr. John Doe for chronic lower back pain since 2018.”

Clinical Relationship

The letter should describe the doctor’s relationship with the veteran, including frequency of visits, treatment history, and ongoing care.

Bad Example:

“I have seen this veteran once and think his back pain is due to military service.”

This is too brief; lacks context or treatment history.

Good Example:

“I have treated Mr. John Doe since January 2018, with follow-up visits every 3–6 months for evaluation and management of chronic lower back pain. My care has included physical exams, imaging review, and therapy management.”

Diagnosis

A clear, specific medical diagnosis is essential. Vague symptoms (like “pain”) are insufficient; the VA needs a formal condition to establish service connection.

Bad Example:

“The veteran has back pain and headaches.”

This only lists symptoms; no formal diagnosis.

Good Example:

“Mr. John Doe has been diagnosed with lumbar degenerative disc disease (ICD-10 M51.36), confirmed by MRI and clinical evaluation, consistent with his reported symptoms and history of service-related physical activity.”

Medical Rationale

The nexus letter must explain why and how the veteran’s condition is connected to military service, using evidence and clinical reasoning rather than assumptions.

Bad Example:

“It is my medical opinion that the veteran back pain is related to service.”

Unsupported opinion; no evidence or reasoning.

Good Example:

“Mr. Doe’s lumbar degenerative disc disease began during active duty after repeated heavy lifting and training exercises. Service treatment records show complaints of back pain during deployment, and post-service imaging confirms progression. Alternative causes such as age-related degeneration, prior injuries, and lifestyle factors have been considered and ruled out as primary contributors.”

What Does a Nexus Letter Look Like?

Your specific condition will significantly influence how your nexus letter will look. Below are a few examples

Primary Connection Letters (Shorter)

Why they’re shorter:

• Primary nexus letters link a condition directly to military service, often based on a well-documented event or in-service injury.

• Since the cause is clear and the service connection straightforward, less explanation is needed.

• VA reviewers can quickly see the link between the condition and service without extensive medical reasoning.

Conditions that don’t need a long letter:

• Back Pain: Veteran injured lifting heavy equipment during service.

• Tinnitus: Hearing loss from exposure to gunfire or machinery.

• PTSD (direct claim): Nexus letters for PTSD usually cover combat trauma, MST, or witnessing a life-threatening event.

• Hypertension: Diagnosed in service with documented elevated readings during active duty.

Secondary Connection Letters (Longer)

Why they’re longer:

• Secondary nexus letters show a condition caused or worsened by another service-connected disability.

• They require more detailed medical reasoning, because the connection is indirect and the VA needs evidence that the primary condition led to the secondary one.

• These letters often include timelines, symptom progression, medical studies, and alternative cause analysis.

Conditions that may need a longer letter:

• PTSD → Sleep Apnea: How chronic stress and disrupted sleep from PTSD contributed to sleep apnea.

• Chronic Back Pain → Hypertension: Chronic pain causing stress, elevated blood pressure, or medication side effects.

• Tinnitus → Head Injury: Head trauma worsening hearing issues and ringing in the ears.

• GERD → Sleep Apnea: Acid reflux linked to sleep disruption, compounded by existing respiratory or stress-related conditions.

Simple Starter Nexus Letter Template

Below is an example of a strong nexus letter template. While you should not copy it word-for-word, it provides a clear illustration of what the VA looks for and how to write your own template effectively.

Header – Credentials & Introduction

I am a licensed [Doctor’s Title], specializing in [Medical Specialty].
I have been evaluating [Veteran Name] since [Start Date], with appointments occurring [Frequency and Nature of Visits], regarding [Condition / Medical Issue].

Purpose of the Letter

This letter provides a medical opinion on [Condition] and its connection to [Veteran Name]’s military service.

Records Reviewed

I reviewed [Veteran Name]’s service treatment records, which show [Key Events].
I also reviewed post-service medical records and diagnostic results. Together, these records provide important context for how [Condition] developed and progressed.

Relevant Medical History & Symptom Timeline

The veteran’s symptoms began [Describe Onset] and have progressed as follows: [Describe Progression and Impact]. These symptoms match [Condition] and are consistent with the veteran’s medical history.

During this time, [Veteran Name] has tried treatments such as [List Treatments], which provided [Describe Effectiveness].

Medical Reasoning and Causation

I considered other possible causes, including [List Alternatives], but found them less likely than a service-related cause.

Supporting evidence includes [List Records / Exams / Buddy Statements / Diagnostics] and supports the connection between [Veteran Name]’s condition and military service because [Give Specific Examples].

Analysis of VA Examination (if applicable)

In reviewing the VA exam from [MM/DD/YYYY], the examiner concluded [Insert VA Examiner’s Conclusion].

After reviewing the veteran’s full medical and symptom history, I find this conclusion [Explain Why Insufficient or Inaccurate].

Formal Nexus Opinion

It is my professional medical opinion that [Condition] is at least as likely as not (50% or greater probability) related to [Veteran Name]’s military service.

Signature Block

Sincerely,
[Doctor’s Name, Title, Credentials]
[Date]

Completed Nexus Letter Example

Below is an example of a nexus letter for a secondary condition. Keep in mind that every case is different, and yours may not require this level of detail

Thompson Sleep Center
Dr. Sarah Thompson, MD – Board-Certified Sleep Specialist
123 Health Way, City, State ZIP
Phone: (555) 123‑4567 | NPI: 1234567890

Date: October 4, 2025

Re: Mr. John M. Reynolds, DOB 03/14/1985
Service: U.S. Army, 2003–2010

To Whom It May Concern:

I evaluated Mr. Reynolds for sleep-related concerns. Based on his clinical history, sleep study results, service records, and ongoing treatment, it is my professional medical opinion that his obstructive sleep apnea (OSA) is at least as likely as not caused or aggravated by his service-connected PTSD.

Diagnosis & Clinical Findings

• Polysomnography (July 22, 2024): moderate OSA, Apnea-Hypopnea Index (AHI) = 23

• Symptoms: chronic sleep disruption, excessive daytime fatigue, morning headaches, loud snoring, gasping, pauses in breathing

• Symptom onset: months after military discharge; persistent despite conservative treatments

Service-Related Factors

• Documented PTSD during military service causing hyperarousal and sleep fragmentation

• In-service nasal trauma contributing to airway obstruction

• PTSD-related medications leading to weight gain, increasing OSA risk

• Literature supports a link between PTSD and OSA:

  • Nighttime arousals and fragmented sleep increase airway collapsibility (pubmed.ncbi.nlm.nih.gov/22893807)

  • CPAP treatment improves both OSA and PTSD symptoms (pubmed.ncbi.nlm.nih.gov/31042558)

Alternative Causes Considered

• Aging: patient is younger than typical idiopathic OSA onset

• General obesity: weight gain correlates with PTSD medication, not pre-existing obesity

• Alcohol use: minimal and controlled

Conclusion / Nexus Opinion
Based on:

• Objective diagnostic testing

• Documented service-connected PTSD and in-service nasal trauma

• Ongoing symptoms despite lifestyle interventions

• Supporting peer-reviewed literature

It is my medical opinion that Mr. Reynolds’ obstructive sleep apnea is at least as likely as not secondary to or aggravated by his service-connected PTSD. This supports his VA claim for secondary service connection.

Sincerely,
Dr. Sarah Thompson, MD
Board-Certified Sleep Specialist
[Signature]

Final Thoughts on Nexus Letters

This guide provides clear, real-world examples of nexus letters to help veterans understand how to effectively establish service connection for their medical conditions.

Each example highlights the critical components that VA reviewers look for, including detailed medical reasoning, references to service records, and precise language linking a condition to military service.

By reviewing these examples, veterans and their healthcare providers can see how a properly drafted nexus letter strengthens a claim, avoids common pitfalls, and increases the likelihood of a successful VA decision.

FAQ

• What does a nexus letter look like?

  A nexus letter can vary in format, but it generally includes the veteran’s diagnosis, relevant medical and service history, and the doctor’s opinion connecting the condition to military service. While the layout differs, the key is that it clearly explains how the condition is “at least as likely as not” related to service.

• Can I write my own nexus letter?

  While a veteran cannot write their own nexus letter, they can create a detailed template or outline to guide their doctor. This template can include the veteran’s medical history, relevant service events, and the specific connection they need the doctor to address. By providing this information, the doctor has a clear roadmap for writing the letter, ensuring it meets the VA’s requirements and strengthens the claim

• Do I need a nexus letter?

  A general rule is that a nexus letter is needed when the VA does not have enough evidence to establish a service connection or when there’s a legitimate question about whether the condition is related to service. Essentially, it’s used to fill gaps in the record and provide the medical opinion necessary to support the claim

• What is a nexus letter?

  A nexus letter is a formal medical opinion written by a licensed healthcare professional linking a veteran’s current medical condition to their military service

• Can I submit a template or copy someone else’s nexus letter?

  No. Templates are only for guidance. Each nexus letter must be individualized for the veteran’s specific claim and supported by medical evidence

• How should evidence be referenced in a nexus letter?

  Cite medical records, service records, diagnostic tests, and relevant peer-reviewed studies. Providing a clear, evidence-based rationale strengthens the opinion

VA Nexus Letters: Ultimate Guide

Many veterans run into the same frustrating problem when it comes to VA nexus letters. They know it’s one of the most important pieces of evidence for a VA disability claim, but getting one feels confusing and overwhelming.

Who writes it? What should it say? And why do so many claims get denied even after a veteran submits a letter?

The truth is, most veterans don’t fully understand what makes a nexus letter strong in the eyes of the VA.

Without the right medical evidence, clear language, and professional backing, the letter can be dismissed or carry little weight. This leads to delays, denials, and veterans feeling stuck in the claims process.

That’s where this guide comes in. We’ll break down everything you need to know about nexus letters. We will cover what they are, why they matter, who can write them, and how to make sure yours gives you the best chance at a successful claim.

What is a Nexus Letter?

A nexus letter is a written medical opinion from a licensed healthcare provider that connects your current disability to your military service — or to another service-connected condition.

In plain terms, it’s a doctor saying:

“It’s at least as likely as not that this veteran’s condition was caused or aggravated by their service.”

You don’t need to prove the connection with 100% certainty — just show there’s an equal or greater chance that service played a role.

Medical Nexus Requirements

A strong nexus letter must:

• Be written by a qualified medical professional (MD, DO, NP, or psychologist).

• Include clear medical reasoning, not just a statement of belief.

• Use VA language such as “at least as likely as not” (50% or greater probability).

• Reference the evidence reviewed — service records, medical files, or exams.

Example:
If a veteran develops PTSD after a documented in-service trauma, the nexus letter should explain how and why that trauma is just as likely to have caused the PTSD as any other factor.

Nexus Letter vs. Nexus Statement

Both show that your condition is service-related — the difference is in depth and detail.

Nexus Letter:

• Full medical opinion from a doctor.

• Includes diagnosis, medical history, and rationale.

• Carries more weight because it’s evidence-based.

Nexus Statement:

• Brief summary that mentions a possible link.

• Lacks detailed explanation or supporting evidence.

• May help, but rarely changes a tough claim on its own.

Always clarify what your provider is giving you — the VA values a detailed, medically reasoned letter far more than a one-paragraph statement.

How It Fits into a VA Claim

To win a VA disability claim, you must prove three things:

1. Current Diagnosis – A verified medical condition.

2. In-Service Event or Injury – Something that happened during service.

3. Medical Nexus – A doctor’s opinion linking the two.

That third element — the nexus — is what this letter provides. Without it, the VA usually can’t grant service connection.

Who Can Write a Nexus Letter?

If you’ve done any research, you’ve probably seen people say a nexus letter only “counts” if it comes from a certain source. The truth is that the quality of reasoning and qualifications of the doctor are what matters most, not who wrote it.

1. Primary Care Provider: A good starting point since they already know your medical history. They offer decent credibility and are often easier to reach locally, especially if you’ve had a long, consistent relationship with them.

2. Nurse Practitioner – While their opinions carry less weight with the VA, they’re typically more accessible and can still help by verifying ongoing symptoms or treatment. These nexus letter work best as supporting evidence.

3. Specialist – Brings high medical credibility and is often necessary for complex or secondary conditions. Specialists can clearly explain how one condition caused or worsened another, though they may be more expensive.

4. Veterans Service Organizations (VSOs) – VSOs can’t write nexus letters, but they’re one of the best free starting points. They can guide you toward reputable doctors and explain what kind of letter you need.

5. Paid Companies – These are easy to access but vary greatly in credibility and quality. They usually have a good understanding of VA language, but are prone to using generic templates. You should only hire a company as a last resort.

In the end, the best source for a nexus letter depends on your specific condition and the doctors available to you.

How Do I Get a Nexus Letter?

Getting a nexus letter takes a bit of preparation, but the process is simple once you know what the VA looks for. Here’s the short version — for full examples and templates, see our step-by-step guide on how to get a nexus letter.

1. Determine if You Actually Need One

Not every claim requires a nexus letter. You typically need a nexus letter if the service connection is unclear, you’re filing for a secondary condition, or your C&P exam didn’t go in your favor.

2. Create a One Page Summary of Your ecords

Organize your service treatment records, VA medical files, private medical notes, and any buddy or lay statements by timeline. You should also document the timeline and severity of your symptoms.

3. Research Thoroughly

Start by asking your own doctor — sometimes they’re willing to provide a medical opinion if you explain exactly what you need.

If that doesn’t work, get recommendations from your local VA Medical Center, a Veterans Service Organization, or explore specialist directories like ABIME for complex cases

4. Ask Doctors the Right Way

Call or meet your doctor in person instead of emailing. Start by asking for a medical opinion, not a “nexus letter”.

Most doctors are more comfortable giving a professional opinion once they understand what you need. If they agree, provide a short summary or template to make it easier for them to review your case

5. Be Patient and Persistent

Most veterans contact several providers before finding one willing to help. Stay organized, follow up politely, and don’t get discouraged. It is absolutely worth it to find the right doctor, even if it takes some time

To properly submit your nexus letter, visit the VA’s Supporting Evidence Page. When uploading online, choose “Supporting Documents or Evidence”.

Nexus Letter Requirements

A strong nexus letter is more than just a doctor’s note—it must meet VA standards to carry weight.

Here’s what a good nexus letter should include:

1. Doctor Credentials – Include the doctor’s name, specialty, board certifications, and ideally a CV to show credibility.

2. Evidence Reviewed – The doctor should address all records including denials, failed C&P exams, and any other evidence mentioned

3. Diagnosis – Clearly state a medical condition the patient has and how they reached that conclusion, including tests, exams, and medical literature if relevant.

4. Medical Reasoning – The most important part. The doctor should clearly explain why the condition is related to military service, reference medical literature, and rule out other likely causes.

5. VA Language – Use VA-specific language, like: “It is at least as likely as not (50% or greater probability) that the veteran’s condition is related to military service.”

6. Signature & Contact – The letter must be signed with full credentials and include contact information for follow-up if the VA needs clarification.

Later, I will show real examples and what applying this information looks like in practice.

Nexus Letter Example & Format

Here is a nexus letter example Below is a sample nexus letter for a veteran with tinnitus caused by prolonged noise exposure during active duty.

Keep in mind that this is a general illustration — every veteran’s case will differ based on their medical history and supporting evidence.

Sample Tinnitus Letter

[Dr. Jane Smith, M.D. – Internal Medicine]
123 Main Street
Richmond, VA 23220
(555) 555-5555
Date: September 11, 2025

Reference: John R. Doe
VA File #: 123-45-6789

To Whom It May Concern:

I am Dr. Jane Smith, a board-certified physician in Internal Medicine, licensed in the state of Virginia. I have been asked to provide a medical opinion in support of Mr. John Doe’s VA disability claim for tinnitus.

I have reviewed Mr. Doe’s service treatment records, VA medical records, and private medical records.

I also reviewed details of his service, which include documented exposure to small arms fire, heavy weapon training, and aircraft engine noise during his active duty from 2005 to 2009.

(Annotation: This shows the doctor reviewed both service records and medical evidence — critical for credibility.)

Mr. Doe has been under my care since March 2020. His current diagnosis is bilateral tinnitus, confirmed through an audiological evaluation dated February 2021, which also showed a mild high-frequency sensorineural hearing loss.

(Annotation: A formal diagnosis and test results anchor the medical legitimacy of the claim.)

He reports persistent ringing in both ears, described as a high-pitched, constant tone that worsens in quiet environments. According to his history, symptoms began in 2007, while assigned to a firing range unit, and have continued without significant remission since separation from service.

(Annotation: This timeline connects the in-service event with ongoing symptoms — key for establishing continuity.)

Mr. Doe denies any history of civilian occupational noise exposure, head trauma, or ototoxic medication use, which could otherwise explain his symptoms.

(Annotation: This rules out alternate causes, which strengthens the doctor’s reasoning.)

After reviewing all available evidence, it is my professional opinion that Mr. Doe’s tinnitus is at least as likely as not (50% probability or greater) the result of his in-service noise exposure.

Rationale:

Service History & Event: Mr. Doe’s service treatment records confirm repeated exposure to weapons fire, artillery, and aircraft noise without consistent hearing protection.

Timeline of Symptoms: Veteran reports onset of ringing during active duty in 2007, with persistence since separation. This is consistent with noise-induced tinnitus as documented in the medical literature.

Medical Reasoning: Chronic noise exposure is a well-established cause of tinnitus. The presence of mild high-frequency hearing loss supports this diagnosis. The absence of significant post-service exposure or other medical explanations further supports a direct service connection.

Sincerely,
Dr. Jane Smith, M.D.
Board Certified in Internal Medicine
Virginia License #: 56789

Do I Need a Nexus Letter for Every Condition?

The biggest thing that determines whether you need a nexus letter is whether you are filing for a primary or secondary condition.

Primary Conditions

Most primary conditions don’t need a nexus letter. These are disabilities that clearly began during service or are directly tied to an in-service injury, illness, or event.

When the service connection is obvious, such as combat related PTSD, the VA usually doesn’t require a separate medical link.

Some exceptions include:

• Your symptoms developed years after discharge but are still tied to something that happened in service.

• Your condition isn’t presumptive — meaning it’s not automatically granted under VA rules.

• A prior C&P examiner said there’s no medical link between your condition and your service.

In these cases, a well-written nexus letter can help fill the gap and give the VA the medical reasoning it needs to approve your claim.

If you can’t get a nexus letter, buddy statements and lay statements can sometimes bridge the gap.

Secondary Conditions

Examples include migraines from a traumatic brain injury, or high blood pressure caused or aggravated by PTSD.

Nexus letters for secondary conditions need to clearly explain the “cause and effect” relationship. They need to show the following things:

1. How the first condition caused or worsened the second.

2. The timeline of each condition

3. Rule out other possible causes, since secondary conditions may have multiple contributing factors.

Without that thorough medical explanation, the VA may not recognize the connection, even if it seems obvious to you.

How Much Do Nexus Letters Cost?

Nexus letters typically cost $500–$3,000, depending on your case and the doctor’s expertise. But price doesn’t equal quality . A well-reasoned $300 letter can be far stronger getting a $2,000 one from a sketchy company.

When It’s Cheap or Free

Sometimes you can get a strong nexus letter for cheap or even free — especially if your VA disability is straightforward and you handle most of the prep yourself.

• You have a good relationship with your PCP: Doctors who know your medical history are more likely to write a letter or include the nexus opinion directly in your records.

• You do research and front-end work: Organizing your evidence, timeline, and summary makes the doctor’s job easier and reduces the time they need to spend reviewing your case.

• You have a relatively simple case: If the link between your service and condition is obvious — like tinnitus or a documented injury — a basic letter from your provider may be enough.

Be prepared to spend a little bit regardless since most doctors want to be paid for their time.

When It’s Expensive

Some nexus letters cost more because the case requires extra time, expertise, or effort to verify.

• You change doctors frequently: Without a consistent provider who knows your history, new doctors must spend more time reviewing records before forming an opinion.

• You have a secondary condition: These claims require detailed medical reasoning to explain how one condition caused or aggravated another, which often means hiring a specialist.

• Limited local resources: If there aren’t many qualified providers nearby, you may need to pay for a specialist review or use an independent medical examiner (IME) online.

If your case is especially complex, it may be worth investing in a specialist who can provide a detailed, well-supported medical opinion that meets VA standards.

What Happens After You Submit a Nexus Letter?

After submitting your nexus letter, the following steps outline how the VA reviews and responds to your claim.

1. How the VA Reviews It

VA raters are required to consider all evidence in your file — including your C&P examination, nexus letter, and service treatment records.

If a C&P exam conflicts with a nexus letter, the VA is supposed to give the benefit of the doubt to the veteran. They don’t favor one source over the other — what matters most is the medical reasoning behind each opinion.

2. How Long It Usually Takes

There’s no fixed timeline. Some claims move in a few weeks, while others take several months, depending on backlog and complexity.

You can track your claim’s progress on VA.gov/claim-or-appeal-status.

3. What to Do if It’s Denied

Unfortunately, the VA process isn’t perfect and the nexus letter success rate can vary widely even if you do everything right

Before appealing, do a thorough audit of your entire submission to make sure your evidence, nexus letter, and medical reasoning are as strong as possible

4. Next Steps: Supplemental Claims, HLR, or Appeals

If you truly believe the VA made a mistake, file a Higher-Level Review (HLR) to have a senior rater reexamine your claim.

If you realize your letter or evidence was incomplete, file a Supplemental Claim with new or stronger documentation.

In more complex or repeated denials, you can take your case to the Board of Veterans’ Appeals for a full review.

Nexus Letter Myths vs Facts

Nexus letters are denied constantly. Below are some common misconceptions about nexus letters and why they are false

Myth: The VA always discounts private nexus letters.

The VA weighs all medical evidence based on its probative value (how detailed, reasoned, and credible it is). A well-supported private opinion can carry just as much weight as a VA doctor’s.

Myth: Paid nexus letters are better than free nexus letters

Paying for a letter doesn’t guarantee success. If the letter is templated or lacks individualized reasoning, it can actually be given less weight by the VA.

Myth: VA doctors are always superior to private doctors.

Neither has automatic priority — what matters is the quality of the medical opinion. In fact, private doctors sometimes provide stronger reasoning, especially if VA examiners overlook evidence.

Myth: If the VA doesn’t mention your nexus letter in the decision, it doesn’t matter.

The VA is required to consider all evidence. If your nexus letter isn’t addressed, that could be a procedural error and grounds for appeal.

Myth: Symptoms alone are enough for a nexus letter.

Symptoms must be tied to a diagnosis and connected to service (or to a service-connected condition). Without that link, a nexus letter won’t hold weight.

Myth: Every VA claim requires a nexus letter.

Not always. If your condition was diagnosed and documented during service, a nexus letter may not be necessary at all.

Final Thoughts on Nexus Letters

In short, a VA nexus letter is a critical tool for proving the connection between your service and your medical condition.

Knowing what it is, who can write it, and what makes it effective can dramatically improve your chances of a successful claim.

By approaching nexus letters strategically and ensuring your letter is credible, well-documented, and tailored to your condition, you give yourself the strongest possible support for your VA disability claim.

FAQ

• How much do Nexus Letters cost for a VA Claim?

  The cost of a nexus letter can vary — some are free, while others may range from around $500 to several thousand dollars. However, a higher price does not automatically mean a better letter. What matters most is finding a trusted doctor who provides a well-reasoned, individualized opinion. Be cautious with paid services that simply copy and paste; the VA gives little weight to generic letters.

• Can veterans write their own Nexus Letter?

  A veteran cannot submit a nexus letter on their own, but they can draft a template, organize supporting evidence, and then have a doctor review and finalize it. This approach is often more affordable than paying for a fully written letter from scratch.

• Do VA doctors write Nexus Letters?

  Technically, VA doctors can write nexus letters, but many choose not to. The reason is often a conflict of interest — their role is to provide treatment within the VA system, not to support or challenge disability claims.

• Do you need a Nexus Letter for secondary conditions?

  Yes, for secondary claims, a nexus letter is even more crucial because it explains how one service-connected condition caused or aggravated another.

• How to ask your doctor to write a Nexus Letter?

  Be direct and professional. Bring your medical records, explain why you believe your condition is service-related, and ask if your doctor feels comfortable providing a medical opinion.

• What document in the VA does a Nexus Letter fall under?

  A nexus letter is treated as medical evidence and becomes part of your VA claims file. It is not a VA form, but supporting documentation for your claim.?

• Do you need a nexus letter for a higher VA rating?

  You generally don’t need a nexus letter for a higher rating if you are already service connected for that condition. You only need one for a rating increase if you are filing for a new condition.