Request for and Authorization to Release Medical Records
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OMB Number: 2900-0260
Estimated Burden: 2 minutes

REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL
RECORDS OR HEALTH INFORMATION
Privacy Act and Paperwork Reduction Act Information: The execution of this form does not authorize the release of information other than that specifically described below. The
information requested on this form is solicited under Title 38, U.S.C. The form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act, 45
CFR Parts 160 and 164, 5 U.S.C. 552a, and 38 U.S.C. 5701 and 7332 that you specify. Your disclosure of the information requested on this form is voluntary. However, if the information
including Social Security Number (SSN) (the SSN will be used to locate records for release) is not furnished completely and accurately, Department of Veterans Affairs will be unable to
comply with the request. The Veterans Health Administration may not condition treatment, payment, enrollment or eligibility on signi