Form Name:Authorization for Release of InformationInvestigator Name:Michael PacakClick here to view a sample form. Your Full Name*Email* Phone*Preferred form of contact Email PhoneHiddenIdentification Number eg Account No Loan No etcHiddenAuthorize Information Obtained From Released toHiddenI Authorize ________ Information to be releasedSocial Security Number*Authorize or Revoke Release of Information* Authorize RevokeSpecify Condition EventThis authorization will remain in effect for 90 days, or until the following condition/event is met (specify):Digital Signature of the Veteran or their Personal Representative*(Authorize)Date* Month Day YearEffective Date of Revocation Month Day YearDigital Signature of the Veteran or their Personal Representative*(Revoke authorization)Date signed* MM slash DD slash YYYY
