Va Form 21-526 - Veteran'S Application For Compensation And/or Pension Page 12

Download a blank fillable Va Form 21-526 - Veteran'S Application For Compensation And/or Pension in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Va Form 21-526 - Veteran'S Application For Compensation And/or Pension with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

SECTION III - CONSENT TO RELEASE INFORMATION

READ ALL PARAGRAPHS CAREFULLY BEFORE SIGNING. YOU MUST CHECK THE APPROPRIATE STATEMENT

UNDERLINED IN PARENTHESES IN PARAGRAPH 9C.

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 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 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.

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)

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:

10A. SIGNATURE OF VETERAN/CLAIMANT OR LEGAL REPRESENTATIVE 10B. RELATIONSHIP TO VETERAN/CLAIMANT

10C. DATE

(If other than self, please provide full name, title,

organization, city, State and ZIP Code. All court