VA Form 21-22a, Appointment of Individual as Claimant's Representative Instructions
This form contains 100 fields organized into 30 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Appointed Representative's Name | ||
| Last Name | Text |
Please enter the last name of the individual appointed as representative.
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| Middle Initial | Text |
Please enter the middle initial of the individual appointed as representative.
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| First Name | Text |
Please enter the first name of the individual appointed as representative.
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| Authorization for Representative's Access to Protected Records | ||
| Authorize disclosure of protected health information | Checkbox |
Check this box if you authorize the VA facility to disclose records related to drug abuse, alcoholism, HIV, or sickle cell anemia to the representative named in Item 16A and any affiliated individuals or firms from Item 19.
|
| Authorization to Change Claimant's Address | ||
| Authorize address change | Checkbox |
Check this box if you authorize the individual named in Item 16A to act on your behalf to change your address in your VA records.
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| Branch of Service | ||
| Army | Combobox |
Enter 'X' if the veteran served in the Army.
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| Navy | Combobox |
Enter 'X' if the veteran served in the Navy.
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| Air Force | Combobox |
Enter 'X' if the veteran served in the Air Force.
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| Marine Corps | Combobox |
Enter 'X' if the veteran served in the Marine Corps.
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| Coast Guard | Combobox |
Enter 'X' if the veteran served in the Coast Guard.
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| Space Force | Combobox |
Enter 'X' if the veteran served in the Space Force.
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| Claimant's Date of Birth | ||
| Claimant's Birth Month | Text |
Enter the claimant's birth month.
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| Claimant's Birth Day | Text |
Enter the claimant's birth day.
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| Claimant's Birth Year | Number |
Enter the claimant's birth year.
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| Claimant's Email Address | ||
| Claimant's Email Address | Text |
Provide the claimant's email address.
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| Claimant's Mailing Address | ||
| Claimant City | Text |
Enter the city of the claimant's mailing address.
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| Claimant Apartment or Unit Number | Text |
Enter the claimant's apartment, unit, or suite number.
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| Claimant Street Address | Text |
Enter the claimant's street number and name, rural route, or P.O. Box.
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| Claimant ZIP+4 Extension | Text |
Enter the four-digit ZIP+4 extension of the claimant's mailing address.
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| Claimant ZIP Code | Text |
Enter the five-digit ZIP code or postal code of the claimant's mailing address.
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| Claimant Country | Text |
Enter the country of the claimant's mailing address.
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| Claimant State or Province | Text |
Enter the state or province of the claimant's mailing address.
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| Claimant's Name | ||
| Claimant's Last Name | Text |
Please enter the claimant's last name.
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| Claimant's Middle Initial | Text |
Please enter the claimant's middle initial.
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| Claimant's First Name | Text |
Please enter the claimant's first name.
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| Claimant's Representative Address | ||
| City | Text |
Please enter the city for the claimant's representative's address.
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| Apartment or Unit Number | Text |
Please enter the apartment, suite, or unit number for the claimant's representative's address, if applicable.
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| Street Address | Text |
Please enter the street number and name for the claimant's representative's address, or a rural route or P.O. Box.
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| ZIP+4 Extension | Number |
Please enter the four-digit ZIP code extension for the claimant's representative's address, if applicable.
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| ZIP/Postal Code | Number |
Please enter the main ZIP or postal code for the claimant's representative's address.
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| Country | Text |
Please enter the country for the claimant's representative's address.
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| State or Province | Text |
Please enter the state or province for the claimant's representative's address.
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| Claimant's Representative Email Address | ||
| Claimant's Representative Email | Text |
Enter the email address of the individual appointed as the claimant's representative.
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| Claimant's Representative Telephone Number | ||
| Area Code | Text |
Enter the area code of the claimant's representative's telephone number.
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| Phone Number Prefix | Text |
Enter the prefix part of the claimant's representative's telephone number.
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| Phone Number Line | Text |
Enter the line number part of the claimant's representative's telephone number.
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| International Phone Number | Text |
Enter the international telephone number of the claimant's representative, if applicable.
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| Claimant's Telephone Number | ||
| Claimant's Phone Area Code | Text |
Enter the area code portion of the claimant's telephone number.
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| Claimant's Phone Prefix | Text |
Enter the prefix portion of the claimant's telephone number.
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| Claimant's Phone Line Number | Text |
Enter the line number portion of the claimant's telephone number.
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| Claimant's International Phone Number | Text |
Enter the claimant's international phone number if applicable.
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| Disclosure to Administrative Employees | ||
| Administrative Employee Names | Text |
Provide the names of the administrative employees of the representative to whom disclosure is authorized.
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| Disclosure to Administrative Employees | Checkbox |
Check this box if you authorize the VA to disclose your records (excluding items 20 and 21) to the administrative employees of your accredited agent or attorney, for disclosures outside of VA electronic IT systems.
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| Disclosure To Affiliated Personnel | ||
| Firm or Organization Name | Text |
Enter the name of the firm or organization affiliated with the representative.
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| Authorize Disclosure to Affiliated Personnel (VA IT Access) | Checkbox |
Check this box if the individual in Item 16A is an accredited agent or attorney approved by the VA for IT systems access, and you authorize the VA to disclose your records to their affiliated associate attorneys, claims agents, and support staff.
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| General | ||
| 17. A. SIGNATURE OF VETERAN (Required only for representation under 14.630) | Signature | |
| 18. A. SIGNATURE OF REPRESENTATIVE NAMED IN 16. A. (Required only for representation under 14.630) | Signature | |
| 25. A. SIGNATURE OF REPRESENTATIVE (Required) | Signature | |
| CONDITIONS OF APPOINTMENT. I, the veteran named in Item 1 or the claimant named in Item 10, hereby appoint the individual named in Item 16. A. as my representative to prepare, present, and prosecute my claims for any and all benefits from VA based on the service of the veteran named in Item 1. If the individual named in Item 16. A. is an accredited agent or attorney, the scope of representation provided before VA may be limited by the agent or attorney as indicated below in Item 24. I authorize VA to disclose any and all of my records (other than as provided in Items 20 and 21) to that individual appointed as my representative and as indicated in Item 19. Signed and accepted subject to the foregoing conditions. 23. A. SIGNATURE OF VETERAN/CLAIMANT (Required) | Signature | |
| Individual Type and Organization | ||
| Service Organization Name | Text |
Provide the full name of the service organization. Fill only if 'Service Organization Representative (Specify organization)' is 'Yes'.
Depends on:
Service Organization Representative (Specify organization)
|
| Attorney | Combobox |
Check this box if you are appointing an attorney as your representative.
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| Agent | Combobox |
Check this box if you are appointing an agent as your representative.
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| Individual Providing Representation Under Section 14.630 | Combobox |
Check this box if you are appointing an individual providing representation under Section 14.630 as your representative.
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| Service Organization Representative (Specify organization) | Combobox |
Check this box if you are appointing a service organization representative and specify the organization.
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| Limitation of Consent | ||
| Consent Limitation Details | Text |
Provide details on how your consent in Item 20 for disclosure of records relating to treatment for drug abuse, alcoholism, HIV, or sickle cell anemia is limited. Fill only if 'Authorize disclosure of protected health information' is checked.
Depends on:
Authorize disclosure of protected health information
|
| Limitations on Representation | ||
| Limitations on Representation | Text |
Enter any specific limitations on the representation provided by the appointed agent or attorney, or state 'none' if no limitations apply. Fill only if 'Individual IS' is 'AGENT' or 'ATTORNEY'.
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| Relationship to Veteran | ||
| Relationship to Veteran | Text |
Please enter the claimant's relationship to the veteran.
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| Representative Signature Date | ||
| Representative Signature Month | Date |
Enter the month of the representative's signature. Fill only if 'INDIVIDUAL PROVIDING REPRESENTATION UNDER SECTION 14.630' is 'Yes'.
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| Representative Signature Day | Date |
Enter the day of the representative's signature. Fill only if 'INDIVIDUAL PROVIDING REPRESENTATION UNDER SECTION 14.630' is 'Yes'.
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| Representative Signature Year | Date |
Enter the year of the representative's signature. Fill only if 'INDIVIDUAL PROVIDING REPRESENTATION UNDER SECTION 14.630' is 'Yes'.
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| Representative Signature Month | Text |
Please provide the month when the representative signed the form.
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| Representative Signature Day | Text |
Please provide the day when the representative signed the form.
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| Representative Signature Year | Text |
Please provide the year when the representative signed the form.
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| Service Number | ||
| Service Number | Text |
Enter the service number for the veteran, if applicable.
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| Social Security Number | ||
| Social Security Number First Part | Text |
Please provide the first three digits of your Social Security Number.
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| Social Security Number Middle Part | Text |
Please provide the middle two digits of your Social Security Number.
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| Social Security Number Last Part | Text |
Please provide the last four digits of your Social Security Number.
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| VA File Number | ||
| VA File Number | Text |
Provide your VA File Number, if applicable.
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| Veteran's Date of Birth | ||
| Veteran's Birth Month | Date |
Enter the two-digit month of the veteran's birth.
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| Veteran's Birth Day | Date |
Enter the two-digit day of the veteran's birth.
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| Veteran's Birth Year | Date |
Enter the four-digit year of the veteran's birth.
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| Veteran's E-mail Address | ||
| Veteran's E-mail Address | Text |
Provide the veteran's email address.
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| Veteran's Mailing Address | ||
| City | Text |
Enter the city of the veteran's mailing address.
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| Apartment/Unit Number | Text |
Enter the apartment, unit, suite, or building number of the veteran's mailing address, if applicable.
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| Street Address | Text |
Enter the building number and street name of the veteran's mailing address, or a rural route or P.O. Box.
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| ZIP Code Extension | Text |
Enter the four-digit extension of the veteran's ZIP code, if applicable.
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| ZIP Code/Postal Code | Text |
Enter the ZIP code or postal code of the veteran's mailing address.
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| Country | Text |
Enter the country of the veteran's mailing address.
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| State/Province | Text |
Enter the state or province of the veteran's mailing address.
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| NOAA | Combobox |
Check if the veteran served in the National Oceanic and Atmospheric Administration.
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| Veteran's Name | ||
| Veteran's Full Name | Text |
Enter the veteran's full name, including first name, middle initial, and last name.
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| Date of Birth | Date |
Enter the veteran's date of birth.
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| VA File Number | Text |
Enter the veteran's VA file number if applicable.
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| Veteran's Social Security Number | ||
| Social Security Number First Part | Text |
Please provide the first three digits of the veteran's Social Security Number.
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| Social Security Number Second Part | Text |
Please provide the middle two digits of the veteran's Social Security Number.
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| Social Security Number Third Part | Text |
Please provide the last four digits of the veteran's Social Security Number.
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| SSN First Part | Text |
Enter the first three digits of the veteran's Social Security Number.
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| SSN Second Part | Text |
Enter the middle two digits of the veteran's Social Security Number.
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| SSN Third Part | Text |
Enter the last four digits of the veteran's Social Security Number.
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| Veteran's Telephone Number | ||
| International Phone Number | Text |
Enter the complete international phone number if applicable.
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| Telephone Number - Line Number | Text |
Enter the four-digit line number of the veteran's local telephone number.
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| Telephone Number - Prefix | Text |
Enter the three-digit prefix of the veteran's local telephone number.
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| Telephone Number - Area Code | Text |
Enter the three-digit area code of the veteran's telephone number.
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| USPHS | Combobox |
Check if the veteran served in the U.S. Public Health Service.
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| Veteran/Claimant Signature Date | ||
| Date Signed (Month) | Text |
Please enter the two-digit month when the veteran or claimant signed the form. Fill only if 'INDIVIDUAL PROVIDING REPRESENTATION UNDER SECTION 14.630' is 'Yes'.
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| Date Signed (Day) | Text |
Please enter the two-digit day when the veteran or claimant signed the form. Fill only if 'INDIVIDUAL PROVIDING REPRESENTATION UNDER SECTION 14.630' is 'Yes'.
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| Date Signed (Year) | Number |
Please enter the four-digit year when the veteran or claimant signed the form. Fill only if 'INDIVIDUAL PROVIDING REPRESENTATION UNDER SECTION 14.630' is 'Yes'.
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| Signature Month | Date |
Please enter the month the veteran or claimant signed the document.
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| Signature Day | Date |
Please enter the day the veteran or claimant signed the document.
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| Signature Year | Date |
Please enter the year the veteran or claimant signed the document.
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