VDVS-VMSDEP FORM 2 Updated August 23, 2020
SIGNER’S ACKNOWLEDGMENT: I HEREBY AUTHORIZE VDVS to review my VA records which contain information that may have been obtained in
connection with a physical, psychological or psychiatric examination or treatment in order to determine my dependent’s eligibility for VMSDEP. I
understand that if my VA records are used to determine my dependent’s eligibility for VMSDEP, the information will no longer be protected by the HIPAA
Privacy Rule, but will be protected by the Federal Privacy Act, 5 USC 552a. VDVS may only disclose this information as authorized by law. I understand
that although VDVS may access my VA records, I will be responsible for providing all information, as identified by VDVS, to fully evaluate my
dependent’s request for VMSDEP eligibility determination. I also understand that I may revoke this authorization in writing; and to revoke, I must send a
written statement to VDVS that I no longer wish to utilize my VA records for VMSDEP eligibility determination; upon which, VDVS would not be able to
process my dependent’s application for VMSDEP benefits.
This acknowledgment endorses the use of my VA records to determine VMSDEP eligibility for following dependent(s):
Veteran’s Signature: __________________________________________ Date: ________________________________________
CONTACT INFORMATION:
Virginia Department of Veterans Services
Veterans Education Training and Employment
Virginia Military Survivors and Dependents Education Program
101 North 14
th
Street, 17
th
Floor
Richmond, VA 23219
Phone: (804) 225-2083
Fax: (804) 786-0809
Email: VMSDEP@dvs.virginia.gov
VIRGINIA DEPARTMENT OF VETERANS SERVICES
AUTHORIZAION TO REVIEW RECORDS IN ORDER TO DETERMINE ELIGIBILITY FOR BENEFITS THROUGH THE
VIRGINIA MILITARY SURVIVORS AND DEPENDENTS PROGRAM (VMSDEP)
Please complete and upload this form to your myVMSDEP account.
PURPOSE: This form serves as notification and authorization that VDVS may access your U.S. Department of Veterans Affairs
(VA) records in order to determine your dependent’s eligibility for the Virginia Military Survivors and Dependents Education
Program (VMSDEP). Your acknowledgment, as endorsed by your signature below, is required for VDVS to process your
dependent’s application.
Dependent's
Dependent's Last Name Dependent's First Name/MI
Veteran's Last Name Veteran's First Name/MI
Last 4 of SSN
Veteran’s
Phone Number
Veteran’s
Email Address
