VMCO PRIVACY RELEASE FORM

I authorize VMCO to make inquires on my behalf and to obtain information from my personal records or files. I certify under penalty of perjury that I provided or authorized all of the information in this privacy release and any documents submitted with it. This authorization includes written correspondence, telephone, or any other means of communication. All agencies are authorized to furnish copies of any documents, correspondence or information relative to my inquiry.

Legal Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Were you referred by anyone or organization?

name or organization

Are you currently in the VA Health Care System*

YesNoI don't know

Do you have your DD214?*

YesNoI don't know

Social Security #*

VA Claim Number (if you have claim)

Who filed the VA Claim?

Approximate date of service (begin to end)*

Military Branch*

Name of Unit, Regiment, Battalion, Ship, etc.

Summarize the problem below*

What specific action are you requesting*

Have you contacted a VSO (Veteran Service Officer) or a Congressional Office for this issue? Must check one.*

YES-fill out info belowNO

If YES, who have you contacted, and what is their contact information*

type name and phone number

Do you authorize release of information to any individual, family member, or attorney? Must Check one*

YES-fill out info belowNO

If YES, who have you authorized, and what is their contact information*

I certify under penalty of perjury that the above information is accurate to the best of my knowledge*

Yes, release information on my behalf

By typing my name below, I authorize VMCO to obtain information on my behalf*

Date of signature*

Date