29-0975
Authorization to Disclose Personal Information to a Third Party (Insurance)
VA Form 29-0975 is the U.S. Department of Veterans Affairs Authorization to Disclose Personal Information to a Third Party (Insurance). The form says to use it to give the VA Insurance Center permission to release personal policy or annuity information to a third party. Its instruction page explains that the VA Insurance Center needs written permission, an authorization, to use or give out claim or benefit information for any purpose that is not permitted by all applicable legal authorities.
The PDF is two pages: a page of information and instructions, then the authorization itself in Items 1 to 11. The form says it may not be executed by a Power of Attorney, that it cannot be used to disclose federal tax information, and that only one VA Form 29-0975 can be on file with the VA Insurance Center at a time. You can fill out the PDF free in your browser on this page and download the result without an account.
The name of the Veteran, the name of an annuitant who is not the Veteran, their address, the insurance policy number, the Social Security number, a daytime phone number, a cell phone number and an email address if applicable.
Checkboxes for Premium Information, Payment History, Loan/Lien Information, Annuity Information, Policy/Award Information, Change of Address, or All.
One time only, ongoing until written notice is given to the VA Insurance Center or a new form is filed, or from the date of signing until a date you specify.
The name and address of the person or organization. For an organization, the form asks for the full name and the title of the organization's representative.
One question to check, such as the city and state your mother was born in or your first pet's name, and its answer. VA asks it each time the third party contacts the office.
A signature in ink and the date signed, followed by the Privacy Act and respondent burden notices.
Page 1 explains each question, from the contact details in Questions 1 to 6 to the security question in Question 10.
Complete Items 1 to 6. The form asks for the names to be printed clearly.
Check one or more boxes in Item 7, then check the box in Item 8 that applies and fill in a date if one is needed.
Enter up to two people or organizations in Item 9. In Item 10, check one security question and give the answer, then let the third party know what the answer is, as the instructions say.
Sign in ink and date Item 11. The instructions say to make a copy of the signed authorization for your records before mailing it to the VA Insurance Center.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
Department of Veterans Affairs, Insurance Center, P. O. Box 5209, Janesville, WI 53547-5209.
The instructions say to notify the VA Insurance Center in writing. After that, it no longer gives out policy information, and the form notes VA is not responsible for information released before the authorization ended.
The APR 2024 edition carries OMB Approved No. 2900-0856, which expires 04/30/2027, with a respondent burden of 5 minutes.
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16 fields, 2 pages
The form and its instructions describe who gives the permission and who receives the information.
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The form says to use it to give the VA Insurance Center permission to release personal policy or annuity information to a third party.
No. The form says it may not be executed by a Power of Attorney.
The instructions say up to two people or organizations. For an organization, the form asks for the full name and the title of its representative.
No. The instructions say only one VA Form 29-0975 can be on file with the VA Insurance Center at a time.
No. The instructions say this form cannot be used to disclose federal tax information to third parties.
The instructions say to notify the VA Insurance Center in writing. Item 8 also offers a one time release or an end date chosen when you sign.
The form lists Department of Veterans Affairs, Insurance Center, P. O. Box 5209, Janesville, WI 53547-5209.