Fillable Printable VA Form 10-5345
Fillable Printable VA Form 10-5345
VA Form 10-5345
Text
10-5345
VA FORM
JUN 2017
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LAST 4 SSNLAST NAME- FIRST NAME- MIDDLE INITIAL
PRIVACY ACT INFORMATION: The execution of this form does not authorize the release of information other than that specifically described below. The
information requested on this form is solicited under Title 38 U.S.C. The form authorizes release of information in accordance with the Health Insurance Portability
and Accountability Act, 45 CFR Parts 160 and 164; 5 U.S.C. 552a; and 38 U.S.C. 5701 and 7332 that you specify. Your disclosure of the information requested on
this form is voluntary. However, if the information including the last four of your Social Security Number (SSN) and Date of Birth (used to locate records for
release) is not furnished completely and accurately, VA will be unable to comply with the request. The Veterans Health Administration may not condition treatment,
payment, enrollment or eligibility on signing the authorization. VA may disclose the information that you put on the form as permitted by law. VHA may make a
“routine use” disclosure of the information as outlined in the Privacy Act system of records notices identified as 24VA10P2 “Patient Medical Record – VA” and in
accordance with the VHA Notice of Privacy Practices. VA may also use this information to identify Veterans and persons claiming or receiving VA benefits and
their records, and for other purposes authorized or required by law.
REQUEST FOR AND AUTHORIZATION TO
RELEASE HEALTH INFORMATION
HEALTH SUMMARY (Prior 2 Years)
OTHER (Describe):
LIST OF ACTIVE MEDICATIONS
RADIOLOGY REPORTS (Name & Date):
DATE RANGE:
SPECIFIC TESTS (Name & Date):
LAB RESULTS:
OPERATIVE/CLINICAL PROCEDURES (Name & Date):
DATE RANGE:
SPECIFIC PROVIDERS (Name & Date Range):
SPECIFIC CLINICS (Name & Date Range):
PROGRESS NOTES:
INPATIENT DISCHARGE SUMMARY (Dates):
TO: DEPARTMENT OF VETERANS AFFAIRS (Name and Address of VA Health Care Facility)
NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL, OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED
DATE OF BIRTH
DESCRIPTION OF INFORMATION REQUESTED
I request and authorize Department of Veterans Affairs to release the information specified below to the organization, or individual named on this
request. I understand that the information to be released includes information regarding the following condition(s):
VETERAN'S REQUEST
DRUG ABUSE
ALCOHOLISM OR ALCOHOL ABUSE
SICKLE CELL ANEMIA
TESTING FOR OR INFECTION WITH HUMAN IMMUNODEFICIENCY VIRUS (HIV)
PURPOSE(S) OR NEED
TREATMENT
OTHER (Specify below)
LEGALBENEFITS
Information is to be used by the individual for:
Check applicable box(es) and state the extent or nature of information to be provided:
DATE (mm/dd/yyyy)PATIENT SIGNATURE (Sign in ink)
UNDER THE FOLLOWING CONDITION(S):
EXPIRATION
UPON SATISFACTION OF THE NEED FOR DISCLOSURE
ON
AUTHORIZATION
I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete to the best of my
knowledge. I understand that I will receive a copy of this form after I sign it. I may revoke this authorization in writing, at any time except to the extent that
action has already been taken to comply with it. Written revocation is effective upon receipt by the Release of Information Unit at the facility housing records.
Any disclosure of information carries with it the potential for unauthorized redisclosure, and the information may not be protected by federal confidentiality rules.
I understand that the VA health care provider’s opinions and statements are not official VA decisions regarding whether I will receive other VA benefits or, if I
receive VA benefits, their amount. They may, however, be considered with other evidence when these decisions are made at a VA Regional Office that specializes
in benefit decisions.
Without my express revocation, the authorization will automatically expire.
(enter a future date other than date signed by patient)
DATE (mm/dd/yyyy)LEGAL REPRESENTATIVE SIGNATURE (if applicable) (Sign in ink)
PRINT NAME OF LEGAL REPRESENTATIVE RELATIONSHIP TO PATIENT
FOR VA USE ONLY
TYPE AND EXTENT OF MATERIAL RELEASED
DATE RELEASED RELEASED BY:
LAST 4 SSNLAST NAME- FIRST NAME- MIDDLE INITIAL DATE OF BIRTH
VA FORM 10-5345, JUN 2017
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