29-0975e Authorization to Disclose Information to a Third Party I

INFORMATION AND INSTRUCTIONS TO HELP YOU COMPLETE THE AUTHORIZATION TO
DISCLOSE PERSONAL INFORMATION TO A THIRD PARTY (INSURANCE)
GENERAL INFORMATION
At the VA Insurance Center, we recognize and respect the importance of privacy. Personal information that
we collect is kept confidential to the extent provided by law. In accordance with the Privacy Act and
applicable confidentiality statutes, the VA Insurance Center will only disclose the information in its custody or
control in the following circumstances: where the individual identifies the particular information and consents
to its use; where disclosure of the information is required by law; or where the disclosure is otherwise legally
permitted, including release for a purpose compatible with the purpose for which it was collected.
By law, the VA Insurance Center must have your written permission (an "authorization") to use or give out
your claim or benefit information for any purpose that is not permitted by all applicable legal authorities. You
may revoke your written permission at any time, except if the VA Insurance Center has already acted based
on your permission.
SPECIFIC INSTRUCTIONS
Questions 1 - 6
In this section, give us your pertinent contact information to include name, address, contact numbers, and
e-mail address.
Question 7
Tell us the type of information you would like the VA Insurance Center to release to your authorized third
party.
Question 8
This section tells the VA Insurance Center the duration of your consent. If you do not want your authorization
to be effective indefinitely, tell us when to stop releasing your personal policy information to your authorized
third party. Check the box that applies and fill in dates, if applicable.
Question 9
The VA Insurance Center will give your personal policy information to the person(s) or organization you fill in
here. You may only select up to two people or organization. If you designate an organization, you must also
identify one or more individuals in that organization to whom the VA Insurance Center may disclose your
policy information. This form cannot be used to disclose federal tax information to third parties.
Question 10
Select the security question you would like us to ask your designated third party and provide the answer.
You, the veteran or annuitant, should answer this question. This question will be asked each time your
designated third party contacts our office, so make sure you let them know what the answer is.

Important Information
You should make a copy of your signed authorization for your records before mailing it to the VA Insurance
Center. You can only have one VA Form 29-0975, Authorization to Disclose Personal Information to a
Third Party, on file with the VA Insurance Center at a time.
WHAT IF I CHANGE MY MIND?
If you change your mind and do not want VA to give out your personal policy information, you may notify us
in writing. Upon notification from you the VA Insurance Center will no longer give out policy information.
(Please note that we are not responsible for information released prior to termination of the third party
authorization.)
VA FORM
APR 2021

29-0975e

OMB Approved No. 2900-0856
Respondent Burden: 5 minutes
Expiration Date: 04/30/2024
(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)

AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION
TO A THIRD PARTY (INSURANCE)
INSTRUCTIONS: Use this form if you want to give the Department of Veterans Affairs Insurance Center permission to release
your personal policy or annuity information to a third party. This form may not be executed by a Power of Attorney.
1. FIRST, MIDDLE, LAST NAME OF VETERAN (Print clearly)

2. FIRST, MIDDLE, LAST NAME OF ANNUITANT WHO IS NOT THE
VETERAN (Print clearly)

3. ADDRESS OF VETERAN/ANNUITANT (No. and Street or rural route, City or P.O., State and ZIP Code)

5. SOCIAL SECURITY NUMBER

4. INSURANCE FILE NUMBER

6. CONTACT INFORMATION

A. DAYTIME PHONE NUMBER

B. CELL PHONE NUMBER

C. E-MAIL ADDRESS (If applicable)

7. I (veteran/annuitant) AUTHORIZE THE DEPARTMENT OF VETERANS AFFAIRS (VA)INSURANCE CENTER TO CONTACT THE PERSON OR
ORGANIZATION LISTED BELOW FOR THE PURPOSES OF PROVIDING THE FOLLOWING INFORMATION PERTAINING TO MY VA RECORD.

(Check one or more boxes below to tell VA the specific policy information you want disclosed or action taken.)

Premium Information

Payment History

Loan/Lien Information

Annuity Information

Policy/Award Information

Change of Address

All

8. THE TERMS OF SUCH RELEASE OF INFORMATION WILL BE:

One time only
Ongoing until written notice is given to VA Insurance Center to terminate or a new form is filed
From the date of signing below until

(Specify date - month, day, year)

9. VA INSURANCE CENTER IS AUTHORIZED TO DISCLOSE THE INFORMATION AS SPECIFIED ABOVE TO THE PERSON(S) OR ORGANIZATION LISTED BELOW.
NOTE: IF AUTHORIZATION IS FOR AN ORGANIZATION, PLEASE PROVIDE THE FULL NAME AND THE TITLE OF THE ORGANIZATION'S REPRESENTATIVE(S).
A. NAME OF PERSON(S) OR ORGANIZATION

B. ADDRESS OF PERSON(S) OR ORGANIZATION

10. SPECIFY THE SECURITY QUESTION YOU WANT USED WHEN VERIFYING THE IDENTITY OF YOUR DESIGNATED THIRD PARTY. CHECK ONLY ONE SECURITY
QUESTION BOX IN 10A AND PROVIDE THE ANSWER IN 10B. (Veteran/annuitant should answer the question and inform third-party of the answer.)
A. SECURITY QUESTION

B. ANSWER

The city and state your mother was born in
The name of the high school you attended
Your first pet's name
Your favorite teacher's name
Your father's middle name
11A. SIGNATURE (Sign in ink)

11B. DATE SIGNED

PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code
of Federal Regulations 1.576 for routine uses identified in the VA system of records, 36VA29, Veterans and Uniformed Services Personnel Programs of U.S. Government Life Insurance - VA,
and published in the Federal Register. Your obligation to respond is voluntary. VA uses your SSN to identify your insurance file. Providing your SSN will help ensure that your records are
properly associated with your insurance file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. The VA will
not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in
effect.
RESPONDENT BURDEN: We need this information to release your private benefit and/or claim information to a designated third party(ies). The execution of this form does not authorize the
release of information other than that specifically described. The information requested on this form will authorize release of the information you specify. Title 38, United States Code, allows
us to ask for this information. We estimate that you will need an average of 5 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a
collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control
numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or
suggestions about this form.
VA FORM
APR 2021

29-0975e