10-3203a
Informed Consent and Authorization for Third Parties to Produce or Record Statements, Photographs, Digital Images, or Video or Audio Recordings
VA Form 10-3203a is the U.S. Department of Veterans Affairs Informed Consent and Authorization for Third Parties to Produce or Record Statements, Photographs, Digital Images, or Video or Audio Recordings. It is a one-page Veterans Health Administration (VHA) form. The person who signs it lets VHA share their name and contact information with a named third party to arrange a meeting, and lets that third party produce or record a statement, photograph, digital image, or video or audio recording of them.
The form has two parts, an Authorization and an Informed Consent, followed by the person's printed name, signature and date. It says participation is voluntary, and that refusing to meet or to sign has no effect on receipt of or eligibility for any VA benefits. VA's form page gives no instructions or mailing address for it. You can fill out the PDF free in your browser on this page and download the result without an account.
Permission for VHA to share the person's name and contact information with the third party to arrange a meeting. The person acknowledges that once shared, the name may no longer be protected by Federal laws or regulations and may be re-disclosed by the third party.
The permission may be revoked in writing at any time, except to the extent the name and contact information were already shared. It expires automatically upon completion of the interview, and the form says expiration does not affect the Informed Consent.
Agreement to meet and, or allow, the third party to produce or record a verbal or written statement, photograph, digital image, or video or audio recording containing the person's voice, appearance, or likeness, and to use it as agreed between them.
VA permits the third party access on property under its jurisdiction on the condition that participation is voluntary. The form says VA and VHA bear no liability for the recordings and that no royalty, fee, or other compensation is payable by the United States.
A statement of the right to refuse at any time, that signing is voluntary, and that refusal has no effect on VA benefits, then lines for Name of Person, Signature of Person and Date.
Write the person's name in the Authorization and in the Informed Consent, and the third party's name in each (Name of 3rd party) blank.
They cover sharing the name and contact information, re-disclosure by the third party, written revocation and automatic expiration after the interview.
They cover what the third party may record and use, access to VA property, liability, compensation and the right to refuse.
Fill in the Name of Person, Signature of Person and Date lines at the bottom of the form.
The form says the person will receive a copy of it after signing.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
Neither the PDF nor VA's form page prints a mailing address, fax number or online submission option for this form.
The form says the permission may be revoked in writing, and that a written revocation is effective upon receipt by the Public Affairs Office.
The form says the person receives a copy after signing it.
The footer reads VA Form NOV 2014 10-3203a. VA's form page lists a form revision date of March 2020. The form is one page.
The form names three parties: the person, VHA and a third party.
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It records a person's consent for a named third party to meet them and produce or record a statement, photograph, digital image, or video or audio recording, and authorizes VHA to share their name and contact information with that third party to arrange a meeting.
The person being met or recorded. The bottom of the form has lines for the Name of Person, Signature of Person and Date.
The form says it may be revoked in writing at any time, except to the extent the name and contact information were already shared. A written revocation is effective upon receipt by the Public Affairs Office.
The form says the authorization to share the name and contact information expires automatically upon completion of the interview with the third party. Expiration does not affect the Informed Consent.
The form says no royalty, fee, or other compensation of any character shall become payable by the United States.
The form says agreeing or refusing to meet with the third party and to sign the form is voluntary, and refusal will have no effect on receipt of or eligibility for any VA benefits.
