Healthcare VA Application

HEALTHCARE VA APPLICATION

Applicant Name:   Last 4 SSN:

Date of Birth:   VA File Number (if any):

Applicant Contact Information

Military Service Information

Entry Date:   Separation Date:

Insurance and Benefits Information

Emergency Contact / Next of Kin

Medical History

Consent, Authorization, and Acknowledgements

By signing below I authorize the release of medical information necessary to determine eligibility for enrollment and to process claims for services rendered. I understand that this authorization includes treatment records, diagnostic results, and billing information, but does not authorize release of psychotherapy notes except where specifically listed.

I consent to examination and treatment by VA-designated health care providers. I understand I may withdraw this consent at any time by submitting a written request to the facility in which I receive care, except to the extent that action has already been taken in reliance on this authorization.

Authorization for Release of Records

I authorize the release of my medical records to the recipient(s) named below for the purpose(s) indicated. This authorization is voluntary and may be revoked in writing at any time, except where disclosure has already been made in reliance on this authorization.

Expiration Date of Authorization:   If no date entered, authorization expires one year from signature.

Certification

I certify that the information provided on this application is true, correct and complete. I understand that knowingly making a false statement on this application may result in denial of benefits, legal penalty, or other administrative action. I authorize verification of any information provided on this form as necessary to determine eligibility and process benefits.

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