Wis. Stats. Chapter 45	P.O. Box 7843, Madison, WI 53707-7843 (608) 266-1311 | 1-800-WIS-VETS (947-8387) | Fax (608) 264-6089
REQUEST FOR RELEASE AND/OR DISCUSSION OF VETERANS RECORDS AND ISSUES
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m)].
The provision of your social security number is voluntary. Failure to provide your social security number may result in an information processing delay.

Veteran’s Name:
Last	First	Middle
Date of Birth:	Social Security or Service Number:
Period of Service:	From:	To:
Month	Year	Month	Year
I hereby authorize the Wisconsin Department of Veterans Affairs (WDVA) to discuss and/or to release any and all of the following records with and to the third party identified below: (Check the appropriate box(es) below to indicate which records should be released.) No records generated in the course of employment with WDVA, irrespective of the content, may be released under this authority.
My applications for benefits with either the United States Department of Veterans Affairs (VA) or Wisconsin Department of Veterans Affairs (WDVA).
VA or WDVA medical treatment records.
VA or WDVA mental health records.
Military separation records.
Department of Defense (DOD) service records.
Any other records maintained by WDVA which were received from the VA or the DOD or were created by WDVA.
Discuss any matter pertaining to this Veteran and any issue which the WDVA is involved with concerning this Veteran.
Person or Organization who may receive and/or discuss my records with WDVA: (Name, Agent, Full Address)
This authorization expires on this specific date:
For Wisconsin Veterans Homes Members, this authorization expires upon death or discharge of the Member.
I release WDVA, the VA, and the DOD for any liability regarding the release or discussion of such records to or with the party I have authorized above. I acknowledge that any subsequent use or disclosure of such records by any entity which obtains such records cannot be controlled or prevented by WDVA, VA, or the DOD. This authorization to release and/or to discuss records is signed without solicitation or the expectation of any consideration.
Authorization is being given by:
Veteran
Veteran’s Duly Authorized Representative* (Proof Required)

Signature of Veteran or Veteran’s Duly Authorized Representative*	Date
Address (Street, City, State, Zip Code)
Type of Photo ID	Photo ID Number
State of Issuance	Expiration Date

IDENTIFICATION REQUIREMENTS:

A photocopy of the authorizing individual’s current ID must be submitted with all mailed or faxed requests.

At least one form of ID must show your current name and current address. Expired cards or documents will not be accepted.

Acceptable forms of identification are:

One of these:

Wisconsin Driver’s License

Wisconsin Photo ID

Out-of-State Driver’s License or Photo ID Card

US Passport

State or Federal DOC Identification Card

OR

Two of these:

Check or Bank Book

Major Credit Card

Health Insurance Card

Recent Dated, Signed Lease

Recent Utility Bill or Traffic Ticket

*Veteran’s Duly Authorized Representative: “Duly authorized representative” means any person authorized in writing by the veteran to act for the veteran, the veteran’s guardian if the veteran is adjudicated incompetent, or a legal representative if the veteran is deceased. Where for proper reason no representative has been or will be appointed, the veteran’s spouse, an adult child, or, if the veteran is unmarried, either parent of the veteran shall be recognized as the duly authorized representative.