The Department of Defense Form 2903-3, also known as the Authorization for the Release of Medical Information is a document that allows healthcare providers to share an individual's protected health information with other entities. The form must be completed by the individual and signed by both the healthcare provider and the individual in order for any protected health information to be released. The Department of Defense Form 2903-3 is used to authorize the release of medical information to third party entities such as life insurance companies, employers, or school officials. The form must be filled out by the individual and signed by both the healthcare provider and the individual in order for any protected health information to be released. Any questions about completing this form should be directed to your healthcare provider
| Question | Answer |
|---|---|
| Form Name | Dd Form 2903 3 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | HRO, dd form 2903 1 fillable form, SSN, dss form 2903 |
VOLUNTARY SEPARATION INCENTIVE PAY AGREEMENT
PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 9902(i), DoDD 1400.25, DoD
PRINCIPAL PURPOSE(S): This form serves as an agreement between a DoD employee and the Department of Defense when Voluntary Separation Incentive Pay (VSIP) has been approved. The agreement certifies the employee has been counseled and freely agrees to and fully understands the conditions and terms of the VSIP.
ROUTINE USE(S): None.
DISCLOSURE: Voluntary; however, failure to provide required information may result in denial of the VSIP.
1.Title 5, United States Code s9902(i) authorizes the Secretary of Defense to establish a program to pay a Voluntary s
Separation Incentive Payment (VSIP) or buyout to eligible employees. This is to certify that my application for the buyout is voluntary and the effective date of my separation shall be
request for the personnel action and the payment terms are irrevocable.
2.I understand that an employee who receives a buyout, and accepts employment with the Government of the United States (including employment in nonappropriated fund instrumentalities or with an agency of the United States through a personal services contract with the United States) within 5 years after the date of separation on which payment of the buyout is based, shall be required to repay the entire amount of the buyout (before taxes and deductions) to the Federal agency that paid the buyout. I also understand that a DoD employee who receives a buyout is prohibited from registering in the DoD Priority Placement Program and may not be reemployed by the Department of Defense in any capacity for a
a.NAME (Last, First, Middle Initial)
b. SSN
3.a. TOTAL BUYOUT AMOUNT
$
b. PAYMENT TERMS |
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Receive one half of my buyout in the amount of $ |
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six months following the date of my separation and the second |
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half in the amount of $ |
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six months later. |
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c. INITIALS
4.This is to certify that I have been counseled by the Human Resources Office (HRO) and that I freely agree to and fully understand the conditions and terms of the buyout.
a. EMPLOYEE SIGNATURE
b.DATE (YYYYMMDD)
c. HRO REPRESENTATIVE SIGNATURE
b.DATE (YYYYMMDD)
DD FORM
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