Fillable Printable VA Form 10-5345a-MHV
Fillable Printable VA Form 10-5345a-MHV
VA Form 10-5345a-MHV
10-5345a-MHV
VA FORM
Page 1 of 2
MAY 2012
DESCRIPTION OF INFORMATION REQUESTED
Check applicable box(es) and state the extent or nature of information to be copied/printed, giving the dates or approximate dates covered by each
VETERAN'S LAST NAME- FIRST NAME- MIDDLE INTIAL
SOCIAL SECURITY NO.
DATE OF BIRTH
FACILITY WHERE TREATED: DATES OF TREATMENT:
COPY OF HOSPITAL SUMMARY
COPY OF OUTPATIENT TREATMENT NOTE(S)
OMB Number: 2900-0260
Estimated Burden: 2 minutes
INDIVIDUALS' REQUEST FOR A COPY OF THEIR OWN
HEALTH INFORMATION
COPY OF HEALTH INFORMATION IS TO BE DELIVERED TO THE INDIVIDUAL
IN-PERSON
BY MAIL, TO ADDRESS BELOW (include City, State & ZIP)
PRIVACY ACT AND PAPERWORK REDUCTION ACT INFORMATION
ThePaperworkReduction Act of 1995requires us to notify you that this information collection is in accordance with
the clearance requirements of section 3507 of the Act. We may not conduct or sponsor, and you are not required to
respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by
all individuals who must complete this form will average 2 minutes. This includes the time it will take to read the
instructions, gather the necessary facts and fill out the form. 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 Veterans Affairs (VA)
in accordance with 38 CFR 1.577.
The information on this form is requested under Title 38, U.S.C. 501. Your disclosure of the information requested on
this form is voluntary. However, if the information including Social Security Number (SSN) (the SSN will be 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 affect on any other benefits to which you may be entitled.
OTHER (Specify)
PATIENT SIGNATURE
DATE (mm/dd/yyyy)
NOTE: If signed by someone other than the patient, indicate the authority (e.g., guardianship or power of attorney) under which request is made.
PHONE NO.
All of my available electronic health records maintained by VHA.
All of my available electronic health records are to be delivered
through My HealtheVet account.
By completing this form, I satisfy a requirement for an authenticated
My HealtheVet account.
10-5345a-MHV
VA FORM
Page 2 of 2
MAY 2012
What is My HealtheVet?
My HealtheVet is an online Personal Health Record (PHR). It enables Veterans to create and maintain a PHR
that includes access to health education information, personal health journals, copies of key portions of VA
patients' electronic health records, and electronic services such as online VA prescription refill requests, Secure
Messaging and more. Some Veterans may view portions of their Department of Defense Military Service
Information.
Authentication
Authentication is a process to verify the Veteran's identity. This provides a level of security that protects your
information. As an authenticated user, you will be able to view copies of key portions of your electronicVA
health record. Additionally, you will have access to your information from other sources as it becomes available.
VA Health Record
Copies of select portions of your VA health record may be viewed in My HealtheVet. Your VA health record is
the official and authoritative record for the VA. .
Privacy and Security
My HealtheVet is a secure website. The VA follows strict security policies and practices. This is to ensure your
personal health information is safe and protected. Once you download your information from My HealtheVet, it
is your responsibility to keep it safe and private.
My Privacy Rights
Veterans who are enrolled for VA health care benefits are afforded various privacy rights in regards to health
information maintained by VA under Federal law and regulations including the right to a notice of privacy
practices. The VA Notice of Privacy Practices advises enrolled veterans of their rights to request access to or
receive a copy of their health information on file with VA; request an amendment to correct inaccurate
information on file with VA; and file a privacy complaint. By receiving a copy of your personal health information
through My HealtheVet you are not giving up any of your privacy rights in regards to the information on file with
VA. A copy of the VA Notice of Privacy Practices, IB 10-163, may be obtained through the Internet at
//www.va.gov/health/default.aspor through the mail by writing the VHA Privacy Office (10P2C1), 810
Vermont Avenue NW, Washington, DC 20420.
//www.va.gov/privacy/
