REQUEST FOR VETERANS SERVICE ORGANIZATION (VSO)
ACCESS TO COMPUTER PATIENT RECORD SYSTEM (CPRS)
READ ONLY
To request access to CPRS Read Only in order to assist a veteran in the preparation of the veteran's claim,
complete Section 1 and submit the form to the Chief, Health Information Management. A single completed
form is necessary for each veteran for whom you hold Power of Attorney (POA). This form will be filed in the
veteran's administrative record.
SECTION 1 (to be completed by the VSO requesting access)
NAME OF REPRESENATIVE
ORGANIZATION
NAME OF VETERAN
SIGNATURE
DATE
SECTION 2 (to be completed by the Chief, Health Information Management, or designee)
I have verified that:
The requestor is a representative of an officially-recognized Veterans Service Organization and is
accredited in accordance with Title 38 United States Code (U.S.C.) s s 14.626-14.635.
The requestor holds valid POA for the veteran listed in Section 1.
DATE
SIGNATURE AND TITLE
NOTE: This form must be filed in the veteran's administrative record, along with a copy of the POA and will
serve
as documentation of
the initial disclosure of information.
ADDITIONAL COMMENTS
10-0400
VA FORM
JUL 2002
REQUEST FOR VETERANS SERVICE ORGANIZATION (VSO)
ACCESS TO COMPUTER PATIENT RECORD SYSTEM (CPRS)
READ ONLY
To request access to CPRS Read Only in order to assist a veteran in the preparation of the veteran's claim,
complete Section 1 and submit the form to the Chief, Health Information Management. A single completed
form is necessary for each veteran for whom you hold Power of Attorney (POA). This form will be filed in the
veteran's administrative record.
SECTION 1 (to be completed by the VSO requesting access)
NAME OF REPRESENATIVE
ORGANIZATION
NAME OF VETERAN
SIGNATURE
DATE
SECTION 2 (to be completed by the Chief, Health Information Management, or designee)
I have verified that:
The requestor is a representative of an officially-recognized Veterans Service Organization and is
accredited in accordance with Title 38 United States Code (U.S.C.) s s 14.626-14.635.
The requestor holds valid POA for the veteran listed in Section 1.
DATE
SIGNATURE AND TITLE
NOTE: This form must be filed in the veteran's administrative record, along with a copy of the POA and will
serve
as documentation of
the initial disclosure of information.
ADDITIONAL COMMENTS
10-0400
VA FORM
JUL 2002
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