Healthcare VA ID Form

HEALTHCARE VA ID FORM

Use this form to request issuance or replacement of a VA Health Identification Card for access to VA medical facilities and services. Completion of this form certifies identity and eligibility information and authorizes verification as described below. False statements or concealment of material facts may result in civil or criminal penalties.

PATIENT INFORMATION

Date of birth:    Gender: Male Female Other Prefer not to say

EMERGENCY CONTACT

SERVICE AND ELIGIBILITY

Branch of service:    Service number or VA file number:

Dates of service: From to

Eligibility status (check all that apply):
Veteran   Service-connected disability   Dependent/Survivor   Other

DD Form 214   Document number:
Military ID   Issuing branch:
State ID / Driver's License   Issuing state:
Passport   Passport number:

INSURANCE / BENEFITS

MEDICAL INFORMATION

PRIVACY, AUTHORIZATION & HIPAA ACKNOWLEDGMENT

By signing below, I certify under penalty of law that the information provided on this form is true and correct to the best of my knowledge. I authorize Veterans Affairs personnel to verify identity and eligibility information provided herein and to retain a photocopy or electronic image of documents submitted in support of this application. I understand that knowingly making false statements or presenting false documents may subject me to penalties under applicable law.

I authorize the release and use of my personal information and limited health information as necessary for verification of identity, provision of health care services, and administration of benefits, consistent with applicable privacy laws and the Health Insurance Portability and Accountability Act (HIPAA). I understand I may revoke this authorization in writing at any time; revocation will not affect disclosures made prior to receipt of the revocation.

Acknowledgment of privacy and authorization: I acknowledge and consent to the statements above.

ISSUANCE AND CARD USE ACKNOWLEDGMENTS

I request issuance (or replacement) of a VA Health Identification Card. I understand this card is property of the VA and is issued for purposes of identification and access to VA health services. I agree to report a lost or stolen card immediately to VA personnel and understand that misuse of the card may result in revocation and administrative action.

Reason for request:

Requested card expiration (if different from standard):

CERTIFICATION

I hereby certify under penalty of perjury that the information provided on this form is true and correct. I authorize verification of any information provided on this form, including verification with third-party records and databases as authorized by law. I understand that knowingly providing false information may result in civil and criminal penalties and administrative actions affecting my eligibility for VA benefits and services.

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