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Vdvs-Vmsdep Form 2 - Authorizaion To Review Records In Order To Determine Eligibility For Benefits Through The Virginia Military Survivors And Dependents Program (Vmsdep) - 2017

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 you online application at the time of submission or

Email to:

VMSDEP@dvs.virginia.gov

; or

Fax to: (804) 786-0809; or

Mail to: VMSDEP, 101 North 14

Street, 17

Floor, Richmond, VA 23219

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.

Last Name

First Name/MI

Applicant’s

Name

Last Name

First Name/MI

Veteran’s Name

Last 4 of SSN

DOB

Veteran’s Home

(

)

Phone

Veteran’s Cell

(

)

Phone

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):

Last Name:

First Name:

Date of Birth:

Veteran’s Signature: __________________________________________

Date: ________________________________________

CONTACT INFORMATION:

Virginia Department of Veterans Services

Veterans Education Training and Employment

Virginia Military Survivors and Dependents Education Program