Va authorization and consent to release ination Form 2021-2024

Va authorization and consent to release ination Form: What You Should Know

Please Note —  1. You must sign the form on page 2. 2. The form may not be signed until we receive a signed copy of the request. 3. You must sign on page 2. 4. You may submit this form up to one time. 5. If you are requesting more than one copy, you must sign in order to authorize additional copies. Signature:  (Note:  If you are a research institution please use the UT Health San Antonio Form D — Authorized by Research Institution — Research Institution. You have completed the  Authorization and Consent — Veterans Benefits Administration form. We have been given your written authorization to release your VA Medical Record to the  research institution.   Signature:  Please enter your name and e-mail address. You may use this form to: Authorize and consent for VA from providing the Veterans Benefits Administration to request and obtain your information by clicking on the button. VA's data use guidelines are found in the Privacy Impact Assessment Guidance to help you understand when VA might share or use your information. You may download the guide here. You have completed: VA-VBA — Request for and Consent to Release VA Medical Records to Research Institutions Signature:  (Note:  There may be many reasons that you may not want the VA to release your veteran medical record. This form can help you understand the legal requirements for using your VBA Records for research. Please click here to view the Authorization and Consent to Use Medical Records for Research Guidance. You received this copy of the VA Form 21-4142-A and request that we  request the following VA Medical Records within ten business days: (A) VBA Code/Information (1/2 Page) VBA Medical Records (6 Pages) (B) VA's information about you. (2) The requested information is necessary for the research to be conducted and for the VA to provide the Veterans Benefits Administration the necessary medical records (such as lab sheets (with/without blood and urine) or imaging) for the purposes of the research. ____________________________ (3) A signed release must be signed before VA will release the requested information VA has the following information regarding your request: 1.

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