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(DO NOT WRITE IN THIS SPACE) AUTHORIZATION TO …

SECTION I - VETERAN IDENTIFICATION INFORMATIONAUTHORIZATION TO DISCLOSE information TO THE DEPARTMENT OF VETERANS AFFAIRS (VA) SECTION III - information REGARDING SOURCE OF RECORD(S) VA FORM JUL 202121-4142 SUPERSEDES VA FORM 21-4142, MAR 2018. OMB Control No. 2900-0858 Respondent Burden: 5 minutes Expiration Date: 07/31/2024 PAGE 1 INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2. Use this form to provide your written AUTHORIZATION to obtain your treatment records, so the VA can get the information required to process your claim. For more information , contact us at , or call us toll-free at 1-800-827-1000.

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

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ADDITIONAL INFORMATION FOR VETERANS …

www.vba.va.gov

additional information for veterans with service-connected permanent and total disability benefits for veterans va€form sep 2006 21-8760 supersedes va …

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OMB Control No. 2900-0745 Respondent Burden: 10 …

www.vba.va.gov

REQUEST FOR CERTIFICATE OF VETERAN STATUS . Privacy Act Notice: This form provides information that is used in determining whether VA can issue a Certificate of Veteran Status which may be beneficial when

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CASE NUMBER COMPLIANCE INSPECTION REPORT

www.vba.va.gov

CASE NUMBER. COMPLIANCE INSPECTION REPORT. NOTE TO BUILDER - Unapproved report left at site for builder's convenience is subject to change. Consult lending institution for OFFICIAL REPORT.

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INSTRUCTIONS FOR COMPLETING APPLICATION …

www.vba.va.gov

important - read these instructions carefully . ... instructions for completing application for burial benefits (under 38 u.s.c., chapter 23) va form apr 2017.

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(DO NOT WRITE IN THIS SPACE) STATEMENT IN ... …

www.vba.va.gov

STATEMENT IN SUPPORT OF CLAIM VA FORM DEC 2017 21-4138€ OMB Control No. 2900-0075 Respondent Burden: 15 minutes Expiration Date: 12/31/2020 EXISTING STOCKS OF VA FORM 21-4138, JAN 2015,

  This, Write, Space, Do not write in this space

YOUR RIGHTS TO APPEAL OUR DECISION with our …

www.vba.va.gov

YOURRIGHTSTOAPPEALOURDECISION HOWCANIAPPEALTHEDECISION? This form will tell you how to appeal to the Board and how to send us more evidence. You can do either one or both of these things. appeal to the Board of Veterans’ Appeals (the Board) by telling us you disagree with our decision

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COUNSELING CHECKLIST FOR MILITARY …

www.vba.va.gov

COUNSELING CHECKLIST FOR MILITARY HOMEBUYERS 1. Failure on the part of a borrower on active duty to disclose that he/she expects to leave the area within

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OMB Control No. 2900-0406 Respondent Burden: …

www.vba.va.gov

TO: NAME AND ADDRESS OF LENDER€(Complete mailing address including ZIP Code) FOR VA USE ONLY (Complete in ink) Veteran . is. exempt from funding fee due to entitlement to VA compensation benefits upon discharge from service.

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REQUEST FOR DETAILS OF EXPENSES

www.vba.va.gov

section iv - hospital and medical expenses. 8. do you expect to make provisions for your children's educational needs, including advanced technical or college education?

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APPEAL TO BOARD OF VETERANS’ APPEALS

www.vba.va.gov

Check the second check box in block 9 if you only want to continue your appeal on some of the issues listed on the SOC and any SSOC you received.

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(For Official Use Only) AUTHORIZATION FOR RELEASE OF ...

www.rush.edu

health information privacy laws, they may further disclose the PHI and it may no longer be protected by federal health informat ion privacy laws. I understand that I have a right to inspect and copy the information to be disclosed pursuant to this authorization and that I may obtain a copy of the information by contacting the office listed above.

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(Sample) Standard Authorization For Disclosure Of Mental ...

www.mamhca.org

(Sample) Standard Authorization For Disclosure Of Mental Health Treatment Information I, _____[Insert Name of Patient/Client], whose Date of Birth is _____, authorize [Insert Name of Mental Health Counseling Organization] to disclose to and/or obtain from: ... Signature of Parent, Guardian or Personal Representative Date If you are signing as a ...

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Authorization to Release Protected Health Information

hospitals.jefferson.edu

Authorization to Release Protected Health Information Form 1. Please complete all sections of the Authorization to Release Protected Health Information Form. 2. The patient or legally authorized representative must sign and date the form. Jefferson may require proof of representation if the form is signed by a personal representative.

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AUTHORIZATION TO DISCLOSE INFORMATION

policies.ncdhhs.gov

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.

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AUTHORIZATION FOR RELEASE OF INFORMATION

www.garnethealth.org

5. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits. I may see or copy the information used/disclosed under this authorization and that I can get a …

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AUTHORIZATION TO DISCLOSE PROTECTED HEALTH …

eforms.com

obtain a signed authorization from the individual or the individual’s legally authorized representative to electronically disclose that indi-vidual’s protected health information. Authorization is not required for disclosures related to treatment, payment, health care operations, performing certain insurance functions, or as may be ...

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