Digital completion: Complete this authorization electronically. Supporting documents will be requested and managed by GVC4Vets after submission.
1 — INDIVIDUAL WHOSE INFORMATION WILL BE DISCLOSED
2 — LAW FIRM INFORMATION
Law firm information will be provided by GVC4Vets — please contact us for assistance.
3 — INFORMATION TO BE DISCLOSED
I authorize the release of any and all information deemed necessary for the purposes stated in this authorization. This may include, but is not limited to:
- Medical records related to my physical or mental health
- Disability Benefits Questionnaires (DBQs)
- Provider evaluations or summaries
- Diagnostic reports (e.g., imaging, laboratory results, psychological assessments)
- Information regarding treatment, diagnosis, and prognosis
- Records pertaining to substance use disorders, psychiatric conditions, or HIV/AIDS status, if applicable
- Service-related documents, including military service treatment records and discharge papers (e.g., DD214)
- Compensation and Pension (C&P) exam results
- Correspondence with the U.S. Department of Veterans Affairs (VA)
- Other relevant documentation submitted to, or received from, the VA or its representatives
4 — PURPOSE OF DISCLOSURE
The purpose of this authorization is to allow the disclosure of my protected health information to the law firm designated by GVC4Vets. Law firm information will be provided by GVC4Vets — please contact us for assistance.
5 — DISCLAIMER
I understand that the records released pursuant to this authorization could contain information concerning drug related conditions, alcoholism, psychological conditions, psychiatric conditions, and/or blood borne infectious disease, which are subject to federal and/or state restrictions on disclosure. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. I hereby affirm that I have read and fully understand the above statements and consent to the disclosure of the medical record for the purpose and extent stated above.
6 — CCPA COMPLIANCE NOTICE
This release is intended to comply with the California Consumer Privacy Act (CCPA). The personal information disclosed under this authorization will not be sold or shared with third parties for monetary gain. The information is released solely at the direction of the individual for the purpose described herein. You may revoke this authorization at any time, and you have the right to request access to or deletion of your personal information under applicable law.
7 — VOLUNTARY NATURE & REVOCATION
This authorization is voluntary and may be revoked at any time in writing. Revocation will not affect any disclosures made prior to receipt of the revocation.
8 — E-SIGNATURE + DATE
By signing above and submitting this form, I authorize the disclosure described in this authorization.
