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Get And Sign NOTE PLEASE READ THE ENTIRE FORM both Pages BEFORE SIGNING IN ITEM 13 BELOW

YOU HAVE MORE THAN FIVE PROVIDERS FILL OUT ADDITIONAL COPIES OF THIS FORM AVAILABLE AT WWW.VA. GOV/VAFORMS. BELOW BEFORE COMPLETING THIS FORM. Under the Government Paperwork Elimination Act GPEA Public Law 105-277 the Office of Management and Budget OMB ensures that agencies when practicable provide for the option of electronic maintenance submission of disclosure of information and for the use and acceptance of electronic signatures. L. 104-191 HIPAA 45 C. F.R. parts 160 and 164 42 U.S.C....

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