Fillable Printable VA Form 10-0400

VA Form 10-0400

REQUEST FOR VETERANS SERVICE ORGANIZATION (VSO)

ACCESS TO COMPUTER PATIENT RECORD SYSTEM (CPRS)

READ ONLY

To request access to CPRS Read Only in order to assist a veteran in the preparation of the veteran's claim,

complete Section 1 and submit the form to the Chief, Health Information Management. A single completed

form is necessary for each veteran for whom you hold Power of Attorney (POA). This form will be filed in the

veteran's administrative record.

SECTION 1 (to be completed by the VSO requesting access)

NAME OF REPRESENATIVE ORGANIZATION

NAME OF VETERAN

SIGNATURE DATE

SECTION 2 (to be completed by the Chief, Health Information Management, or designee)

I have verified that:

The requestor is a representative of an officially-recognized Veterans Service Organization and is

accredited in accordance with Title 38 United States Code (U.S.C.)

14.626-14.635.

The requestor holds valid POA for the veteran listed in Section 1.

SIGNATURE AND TITLE

DATE

NOTE: This form must be filed in the veteran's administrative r ecord, along with a copy of the POA and will

as documentation of serve the initial disclosure of information.

ADDITIONAL COMMENTS

VA FORM

JUL 2002

10-0400