Virginia Authorization to Release Credit Information
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How to fill out Authorization To Release Credit Information?
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FAQ
The purpose of this form is to provide an individual the means to make a written request for a copy of their information maintained by the Department of Veterans Affairs (VA) in ance with 38 CFR 1.577. The information on this form is requested under Title 38, U.S.C.
When to use this form. Use VA Form 21-4142a to give us permission to get medical provider information from a non-VA source like a private doctor or hospital. This will allow us to gather information like the name and address of a facility and your medical treatment dates.
Authorize VA to release your information to a third-party source (VA Form 21-0845)
Use VA Form 10-5345 to authorize us to share your health information with a non-VA (or third-party) individual or organization.
By signing this form, you are giving consent to have your consumer/credit reports furnished by consumer reporting agencies as part of an investigation to determine your suitability or fitness for federal employment or fitness to perform work under a contract.
PATIENT SIGNATURE (Sign in ink) SAME ADDRESS AS ABOVE NEW ADDRESS BELOW IN-PERSON PICK-UP, PROVIDE CONTACT PHONE NUMBER: The purpose of this form is to provide an individual the means to make a written request for a copy of their information maintained by the Department of Veteran Affairs (VA) in ance with 38 CFR ...
Use VA Form 21-0845 to authorize VA to share your personal information with a non-VA (third-party) individual or organization.
Use VA Form 21-4142 to give us permission to obtain your personal information from a non-VA source like a private doctor or hospital. Examples of personal information may include your medical treatment, hospitalizations, psychotherapy, or outpatient care.
