Name and notes
The name of the individual whose statement, likeness or voice is requested, a note on how the material may be used and disclosed, the purpose of the form, and when consent may be rescinded.
10-3203
Consent for Production and Use of Verbal or Written Statements, Photographs, Digital Images, and/or Video or Audio Recordings by VA
- Agency
- VA
- Revision
- January 2026
- Fillable fields
- 35
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-3203: Consent for Production and Use of Statements, Photographs and Recordings
VA Form 10-3203 is the U.S. Department of Veterans Affairs Consent for Production and Use of Verbal or Written Statements, Photographs, Digital Images, and/or Video or Audio Recordings by VA, listed under VHA on VA's page. The form says its purpose is to document a person's consent to VA's request to obtain, produce or use a verbal or written statement, or a photograph, digital image, or video or audio recording containing their likeness or voice.
The form says the person is not required to consent, and that the decision to consent or refuse will not affect access to any present or future VA benefits. Most fields are marked to be completed by VA, including the activity, the facility name, whether use is internal or external, and the purposes. The person signs the consent, and a VA employee records who obtained the permission.
The form is two pages. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 10-3203
Activity and authorization
A description of the activity or situation during the recording, and checkboxes authorizing a named facility, voluntarily and without compensation, to produce a photograph or recording, or to obtain or use a statement.
Use and purposes
Internal or external use, then purposes: promotional efforts, research activities, education purposes such as a presentation, conference, journal publication or training, VA only use such as performance or quality improvement, or all of the above.
Consent statement and signature
The person's statement that no royalty, fee or other compensation will be paid, that consent is voluntary and can be rescinded, then the printed full name, signature and date.
VA employee blocks
Printed names, title, signatures and dates for the employee who obtained permission and the person obtaining consent, plus a note about VA Form 10-5345 when health information is released.
How VA Form 10-3203 is completed
- 1
VA fills in the request
VA completes the activity, facility name, use and purpose boxes. The form says at least one use box is checked as well as a purpose.
- 2
Read the consent terms
The form explains that consent is voluntary, comes without compensation and can be rescinded at any time prior to or during production.
- 3
Sign only after boxes are checked
The form says do not sign this form unless one or more of the boxes above has been checked.
- 4
VA records who obtained consent
The VA employee prints a full name and title and dates the form, and the person obtaining consent prints a name, signs and dates it.
Why fill Form 10-3203 on indox
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Edition and notices
Where it goes
The form prints no mailing address. Its last blocks are completed by the VA employee who obtained the permission.
Rescinding consent
Consent may be rescinded at any time prior to or during production. After production is complete, the form says it may be rescinded if the burden on VA of complying is not unreasonable considering the financial and administrative costs, the ease of compliance and the number of parties involved.
Health information
If VA provides or releases any patient health or demographic information with the material, the form says VA Form 10-5345 is required prior to release to any source outside VA.
Edition
JAN 2026, matching the January 2026 revision date on VA's form page.
Related forms
10-3203a
Informed Consent and Authorization for Third Parties to Produce or Record Statements, Photographs, Digital Images, or Video or Audio Recordings
18 fields, 1 page
10-5345
Request for and Authorization to Release Health Information
61 fields, 2 pages
10-5345a
Individuals' Request for a Copy of Their Own Health Information
43 fields, 1 page
10-1086
Research Consent Form
7 fields, 1 page
Who uses VA Form 10-3203?
The form marks which parts the person completes and which VA completes.
Official sources and the blank
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Questions about Form 10-3203
Is signing VA Form 10-3203 required?
No. The form says you are not required to consent to VA's request, and your decision to consent or refuse will not affect your access to any present or future VA benefits for which you are eligible.
Is the person paid for the use?
The form says no royalty, fee or other compensation of any kind will be made by the United States for such use.
Can consent be taken back?
The form says consent may be rescinded at any time prior to or during production. After production is complete, it may be rescinded if the burden on VA of complying is not unreasonable.
Who fills in the purposes?
VA. The use and purpose boxes are marked to be completed by VA, and the form says do not sign it unless one or more of the boxes has been checked.
How can VA use the material?
The note lists authorized purposes such as education of VA personnel, research activities or promotional efforts, and says it may also be disclosed outside VA as permitted by law and as noted on the form.
What about health information shared with the material?
The form says VA Form 10-5345, Request for and Authorization to Release Medical Records or Health Information, is required before VA releases patient health or demographic information with the material to any source outside VA.