Fillable Printable VA Form 10-5345a

VA Form 10-5345a

Text

10-5345a

VA FORM

JUN 2017

Page 1 of 1

NOTE: If signed by someone other than the individual, indicate the authority (e.g. guardianship or power of attorney) under which request is

made.

PATIENT SIGNATURE (Sign in ink)

MAIL TO ADDRESS:

IN-PERSON PICK-UP, PROVIDE CONTACT PHONE NUMBER:

COPY OF HEALTH INFORMATION IS TO BE DELIVERED TO THE INDIVIDUAL

The purpose of this form is to provide an individual the means to make a written request for a copy of their information maintained by the Department of Veteran

Affairs (VA) in accordance with 38 CFR 1.577. The information on this form is requested under Title 38 U.S.C. 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. Failure to furnish the information will not have any effect on any

other benefits to which you may be entitled.

PRIVACY ACT INFORMATION

INDIVIDUALS' REQUEST FOR A COPY

OF THEIR OWN HEALTH INFORMATION

PAPER CD-ROM OTHER:

DATE OF BIRTHLAST 4 SSNLAST NAME- FIRST NAME- MIDDLE INITIAL

TO: DEPARTMENT OF VETERANS AFFAIRS (Name and Address of VA Health Care Facility)

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):

DESCRIPTION OF INFORMATION REQUESTED

Check applicable box(es) and state the extent or nature of information to be provided:

DATE (mm/dd/yyyy)