; and (B) in person or by fax to the Non-VA Care Communication Office of each medical facility of the Department. (2) Components of statement The Secretary shall require that any veteran that submits a statement in writing described in paragraph (1) include the following: (A) The earliest date that the Department provided to the veteran for an appointment for the receipt of mental health care through a facility or health care provider of the Department, or, if no date was provided, an indication that no appointment date was provided. (B) The earliest date of an appointment of the veteran for the receipt of mental health care that was offered by a non-Department health care provider, if applicable. (C) A certification by the veteran that the veteran cannot reasonably wait for an appointment for mental health care through a facility or health care provider of the Department. (D) Feedback by the veteran with respect to the timeliness and adequacy of mental health care furnished by the Department. (3) Receipt of statement Upon the receipt by the Department of a statement in writing described in paragraph (1) by a veteran, the Secretary shall provide a confirmation to the veteran that the Secretary has received the statement in writing— (A) in the form of an immediate automated confirmation, if the statement in writing was submitted electronically; and (B) in the form of an immediate written confirmation, if the statement in writing was submitted in person or by fax. (c) Conforming amendment Section 101(q)(2)(A) of the Veterans Access, Choice, and Accountability Act of 2014 ( Public Law 113–146 ; 38 U.S.C. 1701 note) is amended— (1) in clause (iii), by striking ; and and inserting a semicolon; (2) in clause (iv), by striking the period at the end and inserting ; and