VA Form 10-5345 "Request for and Authorization to Release Health Information"

This version of the VA Form 10-5345 is not currently in use and is provided for reference only.
Download this version of VA Form 10-5345 to file for the current year.

What Is VA Form 10-5345?

This is a legal form that was released by the U.S. Department of Veterans Affairs on December 1, 2017 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2017;
  • The latest available edition released by the U.S. Department of Veterans Affairs;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;

Download a fillable version of VA Form 10-5345 by clicking the link below or browse more documents and templates provided by the U.S. Department of Veterans Affairs.

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Download VA Form 10-5345 "Request for and Authorization to Release Health Information"

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Text
REQUEST FOR AND AUTHORIZATION TO
RELEASE HEALTH INFORMATION
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.
(Name and Address of VA Health Care Facility)
TO: DEPARTMENT OF VETERANS AFFAIRS
LAST NAME- FIRST NAME- MIDDLE INITIAL
LAST 4 SSN
DATE OF BIRTH
NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL, OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED
VETERAN'S REQUEST
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):
DRUG ABUSE
SICKLE CELL ANEMIA
(HIV)
ALCOHOLISM OR ALCOHOL ABUSE
HUMAN IMMUNODEFICIENCY VIRUS
DESCRIPTION OF INFORMATION REQUESTED
Check applicable box(es) and state the extent or nature of information to be provided:
(Prior 2 Years)
HEALTH SUMMARY
(Dates)
INPATIENT DISCHARGE SUMMARY
:
PROGRESS NOTES:
(Name & Date Range)
SPECIFIC CLINICS
:
(Name & Date Range)
SPECIFIC PROVIDERS
:
DATE RANGE:
(Name & Date)
OPERATIVE/CLINICAL PROCEDURES
:
LAB RESULTS:
(Name & Date)
SPECIFIC TESTS
:
DATE RANGE:
(Name & Date)
RADIOLOGY REPORTS
:
LIST OF ACTIVE MEDICATIONS
(Describe)
OTHER
:
PURPOSE(S) OR NEED
Information is to be used by the individual for:
(Specify below)
TREATMENT
BENEFITS
LEGAL
OTHER
VA FORM
10-5345
Page 1 of 2
DEC 2017
Text
REQUEST FOR AND AUTHORIZATION TO
RELEASE HEALTH INFORMATION
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.
(Name and Address of VA Health Care Facility)
TO: DEPARTMENT OF VETERANS AFFAIRS
LAST NAME- FIRST NAME- MIDDLE INITIAL
LAST 4 SSN
DATE OF BIRTH
NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL, OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED
VETERAN'S REQUEST
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):
DRUG ABUSE
SICKLE CELL ANEMIA
(HIV)
ALCOHOLISM OR ALCOHOL ABUSE
HUMAN IMMUNODEFICIENCY VIRUS
DESCRIPTION OF INFORMATION REQUESTED
Check applicable box(es) and state the extent or nature of information to be provided:
(Prior 2 Years)
HEALTH SUMMARY
(Dates)
INPATIENT DISCHARGE SUMMARY
:
PROGRESS NOTES:
(Name & Date Range)
SPECIFIC CLINICS
:
(Name & Date Range)
SPECIFIC PROVIDERS
:
DATE RANGE:
(Name & Date)
OPERATIVE/CLINICAL PROCEDURES
:
LAB RESULTS:
(Name & Date)
SPECIFIC TESTS
:
DATE RANGE:
(Name & Date)
RADIOLOGY REPORTS
:
LIST OF ACTIVE MEDICATIONS
(Describe)
OTHER
:
PURPOSE(S) OR NEED
Information is to be used by the individual for:
(Specify below)
TREATMENT
BENEFITS
LEGAL
OTHER
VA FORM
10-5345
Page 1 of 2
DEC 2017
LAST NAME- FIRST NAME- MIDDLE INITIAL
LAST 4 SSN
DATE OF BIRTH
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.
EXPIRATION
Without my express revocation, the authorization will automatically expire.
UPON SATISFACTION OF THE NEED FOR DISCLOSURE
(enter a future date other than date signed by patient)
ON
UNDER THE FOLLOWING CONDITION(S):
(Sign in ink)
(mm/dd/yyyy)
PATIENT SIGNATURE
DATE
(if applicable) (Sign in ink)
(mm/dd/yyyy)
LEGAL REPRESENTATIVE SIGNATURE
DATE
PRINT NAME OF LEGAL REPRESENTATIVE
RELATIONSHIP TO PATIENT
FOR VA USE ONLY
TYPE AND EXTENT OF MATERIAL RELEASED
DATE RELEASED
RELEASED BY:
VA FORM 10-5345, DEC 2017
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