Va Form 21-0845 Authorization To Disclose Personal Information
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2INFORMATION AND INSTRUCTIONS TO HELP YOU COMPLETE THE AUTHORIZATION
TO DISCLOSE PERSONAL INFORMATION TO A THIRD PARTY
GENERAL INFORMATION
At VA, we recognize and respect the importance of privacy. Personal information that we collect is kept
confidential to the extent provided by law. In accordance with the Privacy Act and applicable confidentiality
statutes, VA will only disclose the information in its custody or control in the following circumstances: where
the individual identifies the particular information and consents to its use; where disclosure of the information
is required by law; or where the disclosure is otherwise legally permitted, including release for a purpose
compatible with the purpose for which it was collected.
By law, VA must have your written permission (an "authorization") to use or give out your claim or benefit
information for any purpose that is not permitted by all applicable legal authorities. You may revoke your
written permission at any time, except if VA has already acted based on your permission.
SPECIFIC INSTRUCTIONS
Questions 1 - 6
In this section, give us your pertinent contact information to include name, address, contact numbers, and
e-mail address.
Question 7
Tell us the type of information you would like VA to release to your authorized third party.
Question 9
This section tells VA the duration of your consent. If you do not want your authorization to be effective
indefinitely, tell us when to stop releasing your personal benefit or claim information to your authorized third
party. Check the box that applies and fill in dates, if applicable.
Question 10
VA will give your personal benefit or claim information to the person or organization you fill in here. You may
only select one person or one organization. If you designate an organization, you must also identify one or
more individuals in that organization to whom VA may disclose your benefit or claim information. This form
cannot be used to disclose federal tax information to third parties.
Question 11
Select the security question you would like us to ask your designated third party and provide the answer.
This question will be asked each time your designated third party contacts our office.
Where Do I Send My Completed Form?
You can obtain the VA mailing address to send your completed, signed authorization by accessing our
Internet website at or in the government pages of your telephone book under
"United States Government, Veterans."
You should make a copy of your signed authorization for your records before mailing it to VA. You can only
have one active VA Form 21-0845 on file with VA at a time.
WHAT IF I CHANGE MY MIND?
If you change your mind and do not want VA to give out your personal benefit or claim information, you may
notify us in writing, or by telephone at 1-800-827-1000 or electronically via the Internet at https://iris.va.gov.
Upon notification from you VA will no longer give out benefit or claim information (except for the information
VA has already given out based on your permission).
VA FORM
21-0845
(Continued on reverse)
MAY 2010
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