A. A physician or other qualified health care professional who has primary responsibility for treating a veteran who believes the veteran may have been exposed to chemical defoliants or herbicides or other causative agents, including Agent Orange, while serving in the Armed Forces of the United States, shall, at the request of the veteran, submit a report to the Department on a form provided by the Department. If there is no physician or other qualified health care professional having primary responsibility for treating the veteran, the hospital or other medical facility treating the veteran shall, at the request of the veteran, submit the report to the Department.

B. The form provided by the Department to the physician or other qualified health care professional or hospital or other medical facility shall request the following information:

C. The Department may require the veteran to provide such other information as determined by the Commissioner.