Fillable Form VA 21-0845

What is Form VA 21-0845?

If you are a veteran and an organization is requesting information from you about your beneficiaries or claimants, you have to fill out Form VA 21-0845, Authorization to Disclose Personal Information to a Third Party, to express your consent.
Form VA 21-0845 is a form issued by the Department of Veterans Affairs. It is used to confirm the consent of a veteran in disclosing his or her personal information to a third party. It is required by the VA before releasing any documents from their records.

Who Can Fill Out Form VA 21-0845?

Only the veterans who wish to disclose their information should fill out this form. It is to confirm their identity and ensure that they consent to disclosing their information.

How to Fill Out Form VA 21-0845

In this form, you are required to answer questions that are divided into four sections. The questions and the sections are further explained below.

Section I (Items 1-5) - Veteran’s Identification
In this section, you will be required to provide your personal information. Make sure that the information you provide is accurate and matches the information provided on your records:

1. Full name (First, Middle, Last)
2. Social Security Number
3. VA File Number (if known)
4. Date of birth
5. Veteran’s Service Number

Section II (Items 6-9) - Beneficiary’s Identification
In this section, you will be required to provide the personal information of your beneficiary or claimant.

6. Name of the beneficiary*
7. Address of beneficiary/claimant
8.Telephone number (including area code)
9. Email address (optional)

*The name to be provided in this section should not be the same name provided in Section 1.

Section III (Items)
Item 10: In this item, you are asked to provide information from the third party requesting your information. The information you will be providing here can be of a representative from the third party organization or of the organization itself. If you input an organization as a whole, provide one or more names of representatives from the said organization.
The representative or the organization that you input here will be the only ones allowed to receive the information, so make sure that the information you provide here is correct.

A. Name of Person
B. Address of Person
C. Name of Organization
D. Address of Organization

NOTE: The names to be written here should NOT be the same names written from Section I and 2.

Item 11. This item asks for the consent of the beneficiary or the claimant to provide his or her information to the third party requester. The beneficiary or claimant can choose to provide only limited information (in this case, he or she proceeds to answer Item 12) or any information (in this case, he or she proceeds to answer Item 13).

Item 12. Only go to Item 12 if you selected “LIMITED INFORMATION” in Item 11. Item 12 shows a list of the information that the beneficiary/claimant can provide. The beneficiary or claimant should select all the items in the list that he or she is willing to provide.

Item 13. Only go to Item 13 if you selected “ANY INFORMATION” in Item 11. In item 13, the beneficiary or claimant is asked about the duration of his or her consent. This item shows three choices, and he or she must choose according to his or her choice.

Item 14. In Item 14, you are asked to provide a security question that will be used in verifying the identity of the third party. There are five security questions to choose from. Choose only one among these and write the answer to the question on the box next to it.
This is important to ensure that your information is received by the right people.

Section 4 - Declaration of Intent
To confirm that you consent in providing your personal information, affix your signature on the box provided. You should also write the date when you signed the form on the space provided.

Where Do I Submit Form VA 21-0845?

When you finish filling out Form VA 21-0845, submit the form to the Department of Veteran Affairs through the following:

Before sending, make a copy of your signed VA forms for you to keep as proof.

Why do I need to fill out this form?
Some organizations may require you to disclose information about your benefits or claims. However, such information is protected by the law, thus, it cannot be disclosed easily.

Citizens have a right to privacy. The government is mandated to protect the personal information provided to them by the citizens. In compliance with the Privacy Act and other laws concerning privacy and security, government agencies are not allowed to give out any information regarding their constituents without their consent.

The VA upholds this right to privacy. The department is responsible for safekeeping the personal information of the veterans. The said information may be pertaining to a veteran’s beneficiaries or claims. Before releasing a veteran’s personal information to a third party, the VA requires veterans to submit Form VA 21-0845 to confirm their consent in compliance with federal laws.

Is there a due date in submitting the form?
There is no due date on when to submit Form VA 21-0845. One may submit the form as requested by authorized persons.

What if I change my mind after I submit the form?
In case you change your mind and decide to take back your consent, contact the VA immediately through the mail (see address on Where Do I Send My Completed Work section in the form), telephone (1-800-827-1000), or email (iris.custhelp.va.gov). The VA will act on your request and refuse to give out your information to the third party. However, if the VA has already given out information, the VA will not be taking them back.

The information that you will be providing in this form will NOT be disclosed to a person or organization other than those who you have written on Item 10.

Form VA 21-0845 can be submitted without other accompanying documents.