"Consent to Release or Obtain Information Form" - Ohio

Consent to Release or Obtain Information Form is a legal document that was released by the Ohio Department of Veterans Services - a government authority operating within Ohio.

Form Details:

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  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Ohio Department of Veterans Services.

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Consent to Release or Obtain
Information Form
This is consent for release of information about: ________________________________________
(Name of Veteran)
________________________________ __________________ ________________________
(Serial Number/Social Security Number) (Branch of Service)
(Date of Birth)
I authorize _____________________________________________________________________
(Name of Provider Agency)
to release or obtain my Military Personnel Records from the Defense Personnel Records
Information System (DPRIS).
This information may be used only in support of applications for benefits from the United States
Department of Veteran Affairs.
I understand I have the right to see this information at any time. I understand that I can revoke this
consent in writing to both the person giving and the person receiving the information. Any
information already released may be used as stated on the consent. I understand the requested or
provided information is to be used to support applications for Veteran benefits.
This consent is valid only until: _____________________________________________________
(Date Consent Expires)
This consent is not automatically renewable. It expires automatically at the end of the period
specified unless revoked in writing sooner. By my signature below, I affirm that I have read this
release or it has been read to me, and I understand its content.
____________________________________________
________________________
Veteran’s Signature
(Date)
______________________________________________________________________________
Veteran’s address
Prohibition on re-disclosure: This information has been disclosed to you from records
whose confidentiality is protected by federal law. Federal regulations prohibit further
disclosure without specific written consent from the person to who it pertains. Enclosure 3
Consent to Release or Obtain
Information Form
This is consent for release of information about: ________________________________________
(Name of Veteran)
________________________________ __________________ ________________________
(Serial Number/Social Security Number) (Branch of Service)
(Date of Birth)
I authorize _____________________________________________________________________
(Name of Provider Agency)
to release or obtain my Military Personnel Records from the Defense Personnel Records
Information System (DPRIS).
This information may be used only in support of applications for benefits from the United States
Department of Veteran Affairs.
I understand I have the right to see this information at any time. I understand that I can revoke this
consent in writing to both the person giving and the person receiving the information. Any
information already released may be used as stated on the consent. I understand the requested or
provided information is to be used to support applications for Veteran benefits.
This consent is valid only until: _____________________________________________________
(Date Consent Expires)
This consent is not automatically renewable. It expires automatically at the end of the period
specified unless revoked in writing sooner. By my signature below, I affirm that I have read this
release or it has been read to me, and I understand its content.
____________________________________________
________________________
Veteran’s Signature
(Date)
______________________________________________________________________________
Veteran’s address
Prohibition on re-disclosure: This information has been disclosed to you from records
whose confidentiality is protected by federal law. Federal regulations prohibit further
disclosure without specific written consent from the person to who it pertains. Enclosure 3