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

What Is VA Form 10-5345?

VA Form 10-5345, Request for and Authorization to Release Health Information is a document issued by the Department of Veterans Affairs (VA). It is used to get a veteran's written and signed authorization to release their medical data according to the Health Insurance Portability and Accountability Act. The VA may also apply the details provided in this paper to identify the individuals claiming or receiving any VA benefits.

The latest version of the form was released by the VA in September 2018. An up-to-date fillable version of the form is available for download below or can be found on the VA website.

You are required to submit your request to VA if you need to disclose your medical data to any individual or organization for treatment, employment, legal or other purposes. You must fill out this document when submitting an application for VA benefits.

VA Form 10-5345 has two related forms:

  1. VA Form 10-5345a, Individuals' Request for a Copy of Their Own Health Information, used for requesting a copy of a health record maintained by the VA.
  2. VA Form 10-5345a-MHV, Individual's Request for Med Record from MyHealtheVet, used to request a copy of a medical record through a MyHealtheVet account.
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Text
REQUEST FOR AND AUTHORIZATION TO
RELEASE HEALTH INFORMATION
PRIVACY ACT AND PAPER WORK REDUCTION ACT INFORMATION: The Paperwork Reduction Act of 1995 requires 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 is 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 this form. 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. 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. VA may also use this
information to identify veterans and person 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
PURPOSE(S) OR NEED: Information is to be used by the individual for:
(Please specify)
TREATMENT
BENEFITS
LEGAL
EMPLOYMENT
OTHER
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:
(Dose, Lot Number, Date & Location)
FLU VACCINATION
:
(Describe)
OTHER
:
VA FORM
10-5345
Page 1 of 2
SEP 2018
Text
REQUEST FOR AND AUTHORIZATION TO
RELEASE HEALTH INFORMATION
PRIVACY ACT AND PAPER WORK REDUCTION ACT INFORMATION: The Paperwork Reduction Act of 1995 requires 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 is 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 this form. 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. 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. VA may also use this
information to identify veterans and person 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
PURPOSE(S) OR NEED: Information is to be used by the individual for:
(Please specify)
TREATMENT
BENEFITS
LEGAL
EMPLOYMENT
OTHER
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:
(Dose, Lot Number, Date & Location)
FLU VACCINATION
:
(Describe)
OTHER
:
VA FORM
10-5345
Page 1 of 2
SEP 2018
LAST NAME- FIRST NAME- MIDDLE INITIAL
LAST 4 SSN
DATE OF BIRTH
SENSITIVE DIAGNOSES: REVIEW AND, IF APPROPRIATE, COMPLETE WHEN RELEASE IS FOR ANY PURPOSE
OTHER THAN TREATMENT.
I request and authorize Department of Veterans Affairs to release the information pertaining to the condition(s) below for the non-treatment
purpose(s) listed in this authorization.
DRUG ABUSE
ALCOHOLISM OR ALCOHOL ABUSE
SICKLE CELL ANEMIA
(HIV)
HUMAN IMMUNODEFICIENCY VIRUS
I understand that information on these sensitive diagnoses may be released for treatment purposes without me checking the above boxes, and will be
released even if the boxes are unchecked unless I indicate by checking the box below that I do not want this information released for this specific
disclosure.
I do not want sensitive diagnoses released for treatment purposes under this specific authorization. I realize this does not impact
other future requests unrelated to this authorization.
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.
AFTER ONE-TIME DISCLOSURE, IF ALL NEEDS ARE SATISFIED
(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, SEP 2018
Page 2 of 2

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

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VA Form 10-5345 Instructions

VA Form 10-5345 instructions are the following:

  • The document must contain accurate and complete information;
  • Though the disclosure of the data is voluntary, VA will not be able to process the request if the last four digits of your Social Security number (SSN) and your date of birth will be provided;
  • The authorization can be recalled at any time;
  • To recall the authorization, it is necessary to submit the corresponding written request. Verbal revocations are not accepted;
  • After completing and signing the VA 10-5345, you will receive the copy of the form. It is required to keep this copy for references; and
  • If you are not able to request the release of medical records, it can be done by your legal representative.

The data provided via this document may be re-disclosed to the same recipient.

How to Fill out VA Form 10-5345?

The document consists of two pages. Most of its fields are self-explanatory. The average time needed to complete the document is about 2 minutes. The VA 10-5345 should be completed as follows:

  1. Enter the name and address of the VA healthcare facility;
  2. Indicate the name and address of the organization or individual to whom medical records are to be released;
  3. Specify the purpose for data disclosure;
  4. Specify the information you want to release in the "Information Requested" section. Check the appropriate boxes and provide details on the date range and nature of information to be disclosed;
  5. If the medical data is released for non-treatment purposes, review and complete the "Sensitive Diagnoses" section. The information on the diagnoses mentioned in this section will be disclosed for treatment purposes without your consent. If you do not wish the information to be disclosed, to check the box below that states your refusal to release this specific information;
  6. Read the authorization statement carefully;
  7. Select the authorization expiration date or conditions in the "Expiration" section; and
  8. Sign and date the form. The paper can be signed by your legal representative.

The bottom of the form is reserved for VA use only.

Where to Send VA Form 10-5345?

The completed and signed VA 10-5345 should be sent to the specific VA health care facility where the veteran was treated. In case you need to release medical information concerning treatment in several different VA healthcare facilities, you are required to submit the separate form to each of them.

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