NOTE - PLEASE READ THE ENTIRE FORM (both pages) BEFORE SIGNING IN ITEM 11 BELOW - vba va 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with SECTION I, where you will authorize the release of your medical records. Ensure you check all relevant boxes that apply to your treatment history.
3. Proceed to SECTION II and fill in your personal identification details, including your last name, first name, middle name, date of birth, and Social Security number or VA file number.
4. In SECTION III, provide the patient identification for records being requested. This includes filling out the same personal details for the patient as required.
5. SECTION IV requires you to list all sources of medical records. Be thorough in identifying hospitals, clinics, and other providers who have treated you.
6. Finally, in SECTION V, review the authorization and consent section carefully before signing. Make sure to include your signature and date in Item 11.

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