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Before completing this form, read the privacy act and respondent burden on page 2 Fill out the claimant's name, social security number, and contact information in the designated fields. 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.

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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. Carefully read the form instructions to understand the required information The form must be completed in order for the va to obtain information regarding your medical treatments and history

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This information will be needed in order to determine your eligibility for va benefits.

Examples of personal information may include your medical treatment, hospitalizations, psychotherapy, or outpatient care. Use this form to submit a formal statement to support your va claim—or the claim of another veteran or eligible family member People also sometimes call this statement a “buddy statement.” you can submit this form online or by mail.