Fillable Form VA 10-5345
VA Form 10-5345 Fillable is used by veterans who have been treated health care facility that requests and authorizes Department of Veteran Affairs to release information to an individual or organization.
What is Form VA 10-5345?
Form VA 10-5345, Request For And Authorization To Release Health Information, is a Department of Veterans Affairs form used by veterans who have been treated at a health care facility. The document is used to request and authorize the Department of Veterans Affairs to release the veterans’ information to an individual or organization.
Form VA 10 5345 allows the collection of treatment records for doctors or any health care provider, once their active duty is completed. These records are collected and prepared as per the veteran's request usually for the purposes of treatment, benefits, legal, or employment matters.
The information requested on VA 10-5345 Form is solicited under Title 38 of the U.S. Code. The form authorizes the release of information in accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164; 5 U.S. Code 552a; and 38 U.S. Code 5701 and 7332 that you specify.
Your disclosure of the information requested on VA Form 10-5345 is voluntary. However, if the information including the last four digits of your Social Security Number (SSN) and date of birth (used to locate records for release) is not furnished completely and accurately, the Veterans Affairs (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.
The Veterans Affairs (VA) may disclose the information that you put on VA Form 10 5345 as permitted by law. The VA 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”, 08VA05 “Employee Medical File System Records (Title 38) – VA” and in accordance with the Notice of Privacy Practices. The 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.
How to fill out Form VA 10-5345?
Using PDFQuick, you can electronically fill out and download a PDF copy of the VA 10 5345 Form in minutes. Fill it out by following the instructions below.
To: Department of Veterans Affairs
Enter the name and the address of the VA Health Care Facility.
Last Name, First Name, Middle Initial
Enter your full name following the format: Last Name, First Name, Middle Initial.
Last 4 SSN
Enter the last four (4) digits of your social security number (SSN).
Date of Birth
Enter your date of birth following the format: MM/DD/YYYY.
Name and Address of Organization, Individual, or Title of Individual to whom information is to be released
Enter the name and address of the organization, individual, or title of the individual to whom the information is to be released.
Purpose(s) or Need
Mark the appropriate boxes indicating the purpose or need the information is to be used for. You may select:
Information Requested
Mark the appropriate boxes and state the extent or nature of the information to be provided. You may select:
— Specific Clinics – Enter the name and date range in the space provided.
— Specific Providers – Enter the name and date range in the space provided.
— Date Range – Enter the date range in the space provided.
— Specific Tests – Enter the name and date range in the space provided.
— Date Range – Enter the date range in the space provided.
Last Name, First Name, Middle Initial
Enter your full name following the format: Last Name, First Name, Middle Initial.
Last 4 SSN
Enter the last four (4) digits of your social security number (SSN).
Date of Birth
Enter your date of birth following the format: MM/DD/YYYY.
Sensitive Diagnoses
Mark the appropriate box if you’re requesting and authorizing the Department of Veterans Affairs to release the information pertaining to the conditions below for the non-treatment purposes listed in this authorization. You may select:
Mark this box if you do not want these sensitive diagnoses to be released for specific disclosure.
Expiration
Mark the appropriate box indicating when this authorization will expire. You may select:
Note that without your express revocation, this authorization will automatically expire.
Patient Signature
Affix your signature, preferably in ink.
Date
Enter the date you signed the form following the format: MM/DD/YYYY.
Legal Representative Signature
Affix your legal representative’s signature, if applicable, preferably in ink.
Date
Enter the date your legal representative signed the form following the format: MM/DD/YYYY.
Print Name of Legal Representative
Enter the printed name of your legal representative.
Relationship to Patient
Enter your relationship with your legal representative.
For VA Use Only
This section is for Veterans Affairs (VA) use only.
Type and Extent of Material Released
Enter a detailed description of the type and extent of the material released.
Date Released
Enter the date the material was released following the format: MM/DD/YYYY.
Released By
Enter the name of the person who released the material.