the source shown in Item 7A to release or disclose any information or
records relating to the diagnosis, treatment or other therapy for the condition(s) of drug abuse, alcoholism or alcohol abuse, infection
with the human immunodeficiency virus (HIV), sickle cell anemia or psychotherapy notes. IF MY CONSENT TO THIS
INFORMATION IS LIMITED, THE LIMITATION IS WRITTEN HERE:
9A. Privacy Act Notice: The VA will not disclose information collected on this form to any source other than what has been authorized under the
Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional
communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a
party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education, and Rehabilitation Records - VA, and
published in the Federal Register. Your obligation to respond is voluntary. However, if the information including your Social Security Number
(SSN) is not furnished completely or accurately, the health care provider to which this authorization is addressed may not be able to identify and
locate your records, and provided a copy to VA. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your
records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself
will not result in the denial of benefits. The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of
the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect.
11B. DATE
READ ALL PARAGRAPHS CAREFULLY BEFORE SIGNING. YOU MUST CHECK THE
APPROPRIATE STATEMENT UNDERLINED IN PARENTHESES IN PARAGRAPH 9C.
11C. MAILING ADDRESS OF WITNESS
11A. SIGNATURE OF WITNESS
10D. MAILING ADDRESS (Number and Street or rural route, city, or P.O. State and ZIP Code) 10E. TELEPHONE NUMBER (Include Area Code)
10A. SIGNATURE OF VETERAN/CLAIMANT OR LEGAL REPRESENTATIVE 10B. RELATIONSHIP TO VETERAN/CLAIMANT
(If other than self, please provide full name, title,
organization, city, State and ZIP Code. All court
appointments must include docket number, county
and State)
10C. DATE
PAGE 2
SECTION III - CONSENT TO RELEASE INFORMATION
The signature and address of a person who either knows the person signing this form or is satisfied as to that person's identity is
requested below. This is not required by VA but may be required by the source of the information.
9B. I, the undersigned, hereby authorize the hospital, physician or other health care provider or health plan shown in Item 7A to release any
information that may have been obtained in connection with a physical, psychological or psychiatric examination or treatment, with the
understanding that VA will use this information in determining my eligibility to veterans benefits I have claimed. I understand that the health care
provider or health plan identified in Item 7A who is being asked to provide the Veterans Benefits Administration with records under this
authorization may not require me to execute this authorization before it will, or will continue to, provide me with treatment, payment for health
care, enrollment in a health plan, or eligibility for benefits provided by it. I understand that once my health care provider sends this information to
VA under this authorization, the information will no longer be protected by the HIPAA Privacy Rule, but will be protected by the Federal Privacy
Act, 5 USC 552a, and VA may disclose this information as authorized by law. I also understand that I may revoke this authorization, at anytime
(except to the extent that the health care provider has already released information to VA under this authorization) by notifying the health care
provider shown in Item 7A. Please contact the VA Regional Office handling your claim or the Board of Veterans' Appeals, if an appeal is pending,
regarding such action. If you do not revoke this authorization, it will automatically end 180 days from the date you sign and date the form (Item
10C).
9C. I (AUTHORIZE) (DO NOT AUTHORIZE)
