18. AUTHORIZATION FOR REPRESENTATIVE'S ACCESS TO RECORDS PROTECTED BY SECTION 7332, TITLE 38, U.S.C. -
Unless I check the box below, I do not authorize VA to disclose to the individual named in Item 14A any records that may be in my file relating to treatment for drug
abuse, alcoholism or alcohol abuse, infection with the human immunodeficiency virus (HIV), or sickle cell anemia.
CONDITIONS OF APPOINTMENT
I authorize the VA facility having custody of my VA claimant records to disclose to the individual named in Item 14A all treatment records
relating to drug abuse, alcoholism or alcohol abuse, infection with the human immunodeficiency virus (HIV), or sickle cell anemia.
Redisclosure of these records by my representative, other than to VA or the Court of Appeals for Veterans Claims, is not authorized without my
further written consent. This authorization will remain in effect until the earlier of the following events: (1) I revoke this authorization by filing
a written revocation with VA; or (2) I revoke the appointment of the individual named in Item 14A, either by explicit revocation or the
appointment of another representative.
I authorize the individual named in Item 14A to act on my behalf to change my address in my VA records. This authorization does not extend to
any other individual with out my further written consent. This authorization will remain in effect until the earlier of the following events: (1) I
revoke this authorization by filing a written revocation with VA; or (2) I revoke the appointment of the individual named in Item 14A, either by
explicit revocation or the appointment of another representative.
19. LIMITATION OF CONSENT. My consent in Item 18 for the disclosure of records relating to treatment for drug abuse, alcoholism or alcohol abuse, infection
with the human immunodeficiency virus (HIV), or sickle cell anemia is limited as follows:
20. AUTHORIZATION FOR REPRESENTATIVE TO ACT ON CLAIMANT'S BEHALF TO CHANGE CLAIMANT'S ADDRESS -
Unless I check the box below, I do not authorize the individual named in Item 14A to act on my behalf to change my address in my VA records.
I, the person named in Item 1 or 9, hereby appoint the individual named in Item 14A as my representative to prepare,present, and prosecute my
claims for any and all benefits from the Department of Veterans Affairs (VA) based on the service of the veteran named in Item 1. If the individual
named in Item 14A is an accredited agent or attorney, the scope of representation provided before VA may be limited by the agent or attorney as
indicated below in Item 23. If the individual indicated in Item 14A is providing representation under 14.630, such representation is limited to a
particular claim only. I authorize VA to release any and all of my records (other than as provided in Items 18 and 19) to that individual appointed as
my representative, and if the individual in Item 14A is an accredited agent or attorney, this authorization includes the following individually named
administrative employees of my representative:
Signed and accepted subject to the foregoing conditions.
21. SIGNATURE OF CLAIMANT (Do Not Print)
22. DATE OF SIGNATURE
25. DATE OF SIGNATURE (MM/DD/YYYY)
24. SIGNATURE OF REPRESENTATIVE
FEES: Section 5904, Title 38, United States Code, contains provisions regarding fees that may be charged, allowed, or paid for services of agents or attorneys in
connection with a proceeding before the Department of Veterans Affairs with respect to benefits under laws administered by the Department.
23. LIMITATIONS ON REPRESENTATION - AGENTS OR ATTORNEYS ONLY (Unless limited by an agent or attorney, this power of attorney revokes all
previously existing powers of attorney)
VA Form 21-22a, FEB 2019
Page 2
PRIVACY ACT NOTICE: 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 Vocational Rehabilitation and Employment Records -VA, published in the
Federal Register. Your obligation to respond is voluntary. However, failure to respond provide the requested information could impede the recognition of your representative and/or
identification of disclosable records. Except for information protected by 38 U.S.C. 7332, your representative is not prohibited from redisclosing records. The responses you submit are
considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to recognize the individuals appointed by claimants to act on their behalf in the preparation, presentation, and prosecution of claims for
VA benefits (38 U.S.C. 5902, 5903, and 5904) and for those individuals to accept appointment. We will also use the information to verify consent for disclosure of VA records to the appointed
representative (38 U.S.C. 5701(b) and 7332) Title 38, United States Code, allows us to ask for this information. We estimate that claimants and individuals appointed for purposes of
representation will each need an average of 5 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a
valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. A Valid OMB control number can be located on the OMB
Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
VETERAN'S SOCIAL SECURITY NO.
SECTION IV: AUTHORIZATION INFORMATION
PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement of a material fact, knowing it
to be false or for the fraudulent acceptance of any payment to which you are not entitled.
