Va Form 21-4142 - Authorization To Disclose Information To The Department Of Veterans Affairs (Va) Page 2

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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 Vocational Rehabilitation and
Employment Records - VA, 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 source to which this authorization is addressed may not be able to
identify and locate your records, and provide 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.
If you do not revoke this authorization, it will automatically expire in 12 months from the date you sign and date the form. Signing this form is
voluntary, but failing to sign it, or revoking it before we receive necessary information could prevent an accurate or timely decision on your claim,
and could result in denial or loss of benefits. Although the information we obtain with this form is almost never used for any purpose other than those
stated above, the information may be disclosed by VA without your consent if authorized by Federal laws such as the Privacy Act.
Under the Government Paperwork Elimination Act (GPEA) (Public Law 105-277), the Office of Management and Budget (OMB) ensures that
agencies, when practicable, provide for the option of electronic maintenance, submission of disclosure of information and for the use and acceptance
of electronic signatures. GPEA states that electronic records submitted or maintained in accordance with the procedures developed by OMB, or
electronic signature or other forms of electronic authentication used in accordance with such procedures, "shall not be denied legal effect, validity, or
enforceability merely because such records are in electronic form" (Public Law 105-277, section 1707).
RESPONDENT BURDEN: We need this information and your written authorization to obtain your treatment records to help us get the information
required to process your claim. Title 38, United States Code, allows us to ask for this information. You can provide this authorization by signing VA
Form 21-4142. Federal law permits sources with information about you to release that information if you sign a single authorization to release all
your information from all possible sources. We will make copies of it for each source. A few States, and some individual sources of information,
require that the authorization specifically name the source that you authorize to release personal information. In those cases, we may ask you to sign
one authorization for each source and we may contact you again if we need you to sign more authorizations. We estimate that you will 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. Valid OMB control numbers can be located on the OMB Internet Page at
If desired, you may call 1-800-827-1000 to get information on where to send comments or suggestions
about this form. If you use the Telecommunications Device for the Deaf (TDD), the Federal relay number is 711.
PATIENT ACKNOWLEDGMENT: I HEREBY AUTHORIZE the sources listed in Section IV, 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 source being asked to provide the Veterans
Benefits Administration with records under this authorization may not require me to execute this authorization before it provides me with treatment,
payment for health care, enrollment in a health plan, or eligibility for benefits provided by it. I understand that once my source 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 in writing, at any
time except to the extent a source of information has already relied on it to take an action. To revoke, I must send a written statement to the VA
Regional Office handling my claim or the Board of Veterans' Appeals (if my claim is related to an appeal) and also send a copy directly to any of my
sources that I no longer wish to disclose information about me. I understand that VA may use information disclosed prior to revocation to decide my
NOTE: For additional information regarding VA Form 21-4142, refer to the following website:
VA FORM 21-4142, JUN 2014


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