Fillable Printable VA Form 10-3203a

VA Form 10-3203a

INFORMED CONSENT AND AUTHORIZATION FOR THIRD PARTIES TO PRODUCE OR RECORD

STATEMENTS, PHOTOGRAPHS, DIGITAL IMAGES, OR VIDEO OR AUDIO RECORDINGS

NOV 2014

10-3203a

AUTHORIZATION

INFORMED CONSENT

impact the other provisions of the below Informed Consent.

Name of Person

Signature of Person

Date

I understand that no royalty, fee, or other compensation of any character shall become payable to me by the United

States.

VA Form

or to sign this form will have no effect on my receipt of or eligibility for any VA benefits to which I may be eligible.

and to sign this form is voluntary, and my refusal to meet with

to meet me or produce or record a verbal or written statement, photograph, digital image, or video or audio recording

containing my voice, appearance, or likeness.

creates and uses of me.

photograph, digital image, or video or audio recording containing my voice, appearance, or likeness, and on the

condition that my participation is done voluntarily.

I acknowledge that VHA and the Department of Veterans Affairs (VA) are permitting

the use of a verbal or written statement, photograph,

image, or video or audio recording containing my voice, appearance, or likeness.

, agree to meet and / or allow

digital image, or video or audio recording containing my voice, appearance, or likeness as agreed to between me

access to meet with me on the property under its jurisdiction in order for

(Name of Person),

agree to permit the Veterans Health Administration (VHA), if

necessary, to

(Name of 3rd party)

to arrange a meeting. I acknowledge that once my name is

shared pursuant to this authorization, it may no longer be protected by Federal laws or regulations and may be

subject to re-disclosure by

(Name of 3rd party)

I may revoke the permission, in writing, at any time except to the extent my name and contact information has

(Name of 3rd party)

Written revocation is effective upon receipt by

the Public Affairs Office. This authorization to share my name and contact information will automatically expire upon

completion of the interview with

(Name of 3rd party)

Expiration of the authorization does not

(Name of Person),

(Name of 3rd party)

to produce or record a verbal or written statement, photograph, digital

(Name of 3rd party)

already been shared with

I consent to permit

and

to meet me and produce or record a verbal or written statement,

I agree that VA and VHA bear no liability or responsibility for the production and use of any verbal or written

statements, photographs, digital images, or video or audio recordings that

I understand that at any time, I may exercise my right to refuse to allow

I understand that I will receive a copy of this form after I sign it.

I further understand that my agreement or refusal to meet with