VA Form 21 22 Appointment of Veteran Service

VA Form 21 -22 Appointment of Veteran Service Organization as Claimant’s Representative By SCRVSC Staff

Purpose • Provide Spokane County Regional Veteran Service Center (SCRVSC) accredited Veteran Service Officers to act on Veteran’s behalf. • Provide Service an opportunity to quantify our service to Veterans in the community to justify current and future. • Establish a potential long term relationship with Veterans to be able to address future Veteran Benefits.

VA Form 21 -22 Page 1 If Veteran: • Block 1 & 2 Self Explanatory. • Block 3 - If Pre-1970 discharge leave Block 3 Blank. • Block 3 - If Post-1970 Discharge place Social Security Number. • Block 5 – If you were assigned a Service Number, Place in block without letters. • Block 5 – Not assigned different number place Social Security number • Block 6 – Place NA • Block 7, 8 & 9 Mailing Address, Telephone number w/area code, email (is optional)

VA Form 21 -22 Page 1 If Claimant: • Block 1 & 2 Self Explanatory. • Block 3 - If Pre-1970 discharge leave Block 3 Blank. • Block 3 - If Post-1970 Discharge place Social Security Number in Block 3. • Block 5 – If you were assigned a Service Number, Place in block without letters. • Block 5 – Not assigned different number place Social Security number • Block 6 – Place NA • Block 7, 8 & 9 Mailing Address, Telephone number w/area code, email (is optional) Leave Blank • Block 10 -13 Claimant Contact information • Block 14 relationship to Veteran (i. e. Surviving Spouse)

VA form 21 -22 Page 2 Purpose • Due to HIPPAA Requirement you have to provide permission to be able to access certain specially protected medical conditions. • In most cases, the permissions allowed will not apply to what is being addressed in the claim or future claim. • However, if you do restrict access to any part of your Electronic file, it can create difficulties for us to assist you when having to access your claim. • This representation can be revoked by you or our service at most any time, by securing other representation or specifically requesting revocation in writing.

VA Form 21 -22 Ø Place Veteran 2 Social Security Number Page along top in the boxes Ø Block 19 Check box authorizing service the ability to access VA records to assist Veteran in their claim. Ø Block 20 Place in large letters across this section “NONE” (unless there is a limitation you wish to place on access) Ø Block 21 Check box allowing Service to assist you in informing the VA of an Address change. Ø Block 22 A Sign (as you would normally in any other document) and date.

• Thank you for giving us this opportunity to Serve you!