Form Name:Authorization for Release of Information Investigator Name:Jana Oyerbides Click here to view a sample form. Your Full Name*Email* Phone*Preferred form of contactEmailPhoneIdentification Number eg Account No Loan No etc*Authorize Information*Obtained FromReleased toI Authorize ________ Information to be released*Specify Condition Event*This authorization will remain in effect for 90 days, or until the following condition/event is met (specify):Authorize or RevokeAuthorizeRevokeEffective Date of Revocation* Date Format: MM slash DD slash YYYY Digital Signature of the Veteran or their Personal Representative*(Authorize)Digital Signature of the Veteran or their Personal Representative*(Revoke authorization)Date signed* Date Format: MM slash DD slash YYYY
