VA Form 10-5345a-mhv Individuals' Request for a Copy of Their Own Health Information

What Is VA Form 10-5345A-MHV?

VA Form 10-5345A-MHV, Individuals' Request for a Copy of Their Own Health Information (or the Individual's Request for Med Record from My HealtheVet) is a document issued by the Department of Veterans Affairs (VA) and used by veterans to request a copy of their medical data through My HealtheVet account. An up-to-date fillable version of the VA Form 10-5345a-MHV is available for digital filling and download below or can be found on the VA forms website.

The latest version of the form was released by the VA in May 2012 and has two related forms: VA Form 10-5345 (Request for and Authorization to Release Medical Records or Health Information) and the VA Form 10-5345A (Individuals' Request for a Copy of Their Own Health Information).

My HealtheVet is a secure online service that contains Personal Health Records (PHR) of veterans. It allows veterans to access their PHR: health education information, personal health journals, and other electronic services. Some accounts may even view their DoD Military Service Information. To use the service, the veteran has to pass the authentication first. The VA release form 10-5345a-MHV is also applied in the process of veteran's authentication in My HealtheVet and to upgrade the corresponding My HealtheVet account to Premium.

The VA has strict security policies and protects all personal health data uploaded to the website. However, once you download it from My HealtheVet, you become responsible for keeping it safe and private.

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OMB Number: 2900-0260
Estimated Burden: 2 minutes
INDIVIDUALS' REQUEST FOR A COPY OF THEIR OWN
HEALTH INFORMATION
PRIVACY ACT AND PAPERWORK 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 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.
DATE OF BIRTH
VETERAN'S LAST NAME- FIRST NAME- MIDDLE INTIAL
SOCIAL SECURITY NO.
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
FACILITY WHERE TREATED:
DATES OF TREATMENT:
OTHER (Specify)
COPY OF HOSPITAL SUMMARY
COPY OF OUTPATIENT TREATMENT NOTE(S)
All of my available electronic health records maintained by VHA.
COPY OF HEALTH INFORMATION IS TO BE DELIVERED TO THE INDIVIDUAL
IN-PERSON
BY MAIL, TO ADDRESS BELOW (include City, State & ZIP)
PHONE NO.
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.
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.
Page 1 of 2
10-5345a-MHV
VA FORM
MAY 2012
OMB Number: 2900-0260
Estimated Burden: 2 minutes
INDIVIDUALS' REQUEST FOR A COPY OF THEIR OWN
HEALTH INFORMATION
PRIVACY ACT AND PAPERWORK 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 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.
DATE OF BIRTH
VETERAN'S LAST NAME- FIRST NAME- MIDDLE INTIAL
SOCIAL SECURITY NO.
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
FACILITY WHERE TREATED:
DATES OF TREATMENT:
OTHER (Specify)
COPY OF HOSPITAL SUMMARY
COPY OF OUTPATIENT TREATMENT NOTE(S)
All of my available electronic health records maintained by VHA.
COPY OF HEALTH INFORMATION IS TO BE DELIVERED TO THE INDIVIDUAL
IN-PERSON
BY MAIL, TO ADDRESS BELOW (include City, State & ZIP)
PHONE NO.
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.
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.
Page 1 of 2
10-5345a-MHV
VA FORM
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 electronic VA
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
http://www.va.gov/health/default.asp
or through the mail by writing the VHA Privacy Office (10P2C1), 810
Vermont Avenue NW, Washington, DC 20420.
https://www.va.gov/privacy/
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10-5345a-MHV
VA FORM
MAY 2012

Download VA Form 10-5345a-mhv Individuals' Request for a Copy of Their Own Health Information

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VA Form 10-5345A-MHV Instructions

The form includes two pages. The first page is a form the veteran needs to complete. The second contains the information about My HealtheVet, authentication, and VA health record. Moreover, there is data about the privacy and security of health records, as well as the privacy rights of a veteran.

The VA Form 10-5345A-MHV instructions are as follows:

  • You are not required to complete this document unless it displays a valid OMB number.
  • You need to provide all the requested information - including your Social Security number - completely and accurately. Failure to provide the data may result in VA inability to comply with the request.
  • If you are unable to sign the request, it can be signed by your legal representative. In this case, it is required to indicate the authority, e.g. power of attorney or guardianship.

How to Fill out VA Form 10-5345A-MHV?

The VA Form 10-5345A-MHV is self-explanatory and easy to complete. However, if you experience any difficulties, you may schedule an appointment with a My HealtheVet representative in any local VA healthcare facility. The authorized representative will make sure you have viewed the My HealtheVet Orientation Video, provide you with the VA 10 5345A-MHV necessary to complete, answer the questions if any, confirm the document is filled out correctly and the request is succeeded.

You have to enter all the information requested in the document. For the form to be valid and the VA could start the processing it must be signed and dated properly. You are required to indicate the date in MM/DD/YYYY format.

Where to Send VA Form 10-5345A-MHV?

You are required to submit VA Form 10-5345A-MHV completed and signed to the Release of Information Office. These offices are located in all the VA medical facilities. The address of the closest facility can be found online at the VA official website. When submitting a completed form in person, you will need to bring an ID.

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