VA 10-5345 2005 free printable template

DATE mm/dd/yyyy SIGNATURE OF PATIENT OR PERSON AUTHORIZED TO SIGN FOR PATIENT Attach authority to sign e.g. POA FOR VA USE ONLY IMPRINT PATIENT DATA CARD or enter Name Address Social Security Number TYPE AND EXTENT OF MATERIAL RELEASED DATE RELEASED VA FORM JUL 2013 10-5345 RELEASED BY USE EXISTING STOCK OF VA FORM 10-5345 DATED MAY 2005. Redisclosure of my medical records by those receiving the above authorized information may be accomplished without my further written authorization and may...

How to fill out VA 10-5345

How to fill out VA 10-5345

1. Obtain the VA Form 10-5345 from the VA website or a local VA office.
2. Fill out your personal information at the top of the form, including your name, address, and phone number.
3. Indicate the specific medical records you wish to request access to.
4. Specify the date range for the records if applicable.
5. Provide the name and address of the facility where the records are held.
6. Sign and date the form at the bottom to authorize the release of your information.
7. Submit the completed form to the appropriate VA medical facility.

Who needs VA 10-5345?

1. Veterans who want to access their medical records or have them sent to another provider.
2. Individuals seeking to obtain records for benefits or claims assistance.

• Who needs a VA Form 10-5345?
• What is VA Form 10-5345 for?
• Is VA Form 10-5345 accompanied by other forms?
• • When is VA Form 10-5345 due?
  • How do I fill out VA Form 10-5345?
  • Where do I send VA Form 10-5345?

Who needs a VA Form 10-5345?

VA Form 10-5345 is used by veterans who have been treated at a health care facility of the Department of Veterans Affairs.

What is VA Form 10-5345 for?

VA Form 10-5345 is a document whereby a veteran requests and authorizes Department of Veterans Affairs to release information to a particular individual or organization specified in the Form.

Is VA Form 10-5345 accompanied by other forms?

No other form is required to be submitted with VA Form 10-5345. However, if the veteran authorizes a representative to sign the form on his/her behalf, the respective power of attorney should be attached to the Form.

When is VA Form 10-5345 due?

You should ask the treatment facility when the Form is due; it depends on your personal circumstances.

How do I fill out VA Form 10-5345?

In the first box, you should enter the name and address of the health care facility where you were treated; this information may be entered by the facility.

At the beginning of the Form, you should enter your name and social security number.

In “Veteran’s Request” item, you should check the respective boxes: “drug abuse”, “alcoholism or alcohol abuse”, “testing for or infection with HIV”, or “sickle cell anemia”. This is to confirm that you understand that the information to be released may include information about the above-mentioned conditions.

In item “Information requested”, you should check one or more applicable boxes: “copy of hospital summary”; “copies of outpatient treatment notes” or “other (specify)”. In the field that follows you should specify the nature or extent of the information to be disclosed, giving the respective dates.

Your authorization may expire automatically on a certain date or under certain conditions, without your revocation. You may specify such a date or conditions filling the respective boxes in item “Authorization”.

Finally, you should sign and date the Form.

Your disclosure of the information requested on the Form is voluntary. However, if the information provided, including Social Security Number, is incomplete and inaccurate, Department of Veterans Affairs will be unable to comply with the request.

Where do I send VA Form 10-5345?

You should send the completed Form to the facility specified in the first box of the Form.

Instructions and Help about VA 10-5345

Hello welcome to legal help for veterans tutorial videos today we're going to be walking you through the request for an authorization to release medical records or health information form also referred to as be a form 10-5 three four five this form will be one of the forms sent to each client in our initial representation packet the purpose of this form is to authorize the release of your complete treatment records to this office from each respective VA medical center where you treat, although most of this form is very self-explanatory there are several common completion areas we repeatedly see veterans make during the completion of this form the first and most common issue comes right away in box number one please note that this form is only used to obtain medical records from VA and medical centers while your private treatment records can be equally important there is an alternate VA form that will authorize access to these records if you do have private medical records the correct form to use is VA form — on—

People Also Ask about

Does VA release medical records?

To request a copy of your VA medical records by mail or fax, send a signed and completed VA Form 10-5345a to our Release of Information office. We process mailed or faxed requests within 10-14 days. For privacy reasons, we can't accept requests for medical records by email.

How do you get a VA hardship?

To request a VA hardship determination and copay exemption: Fill out a Request for Hardship Determination (VA Form 10-10HS). Get VA Form 10-10HS to download. Write a letter explaining why you're requesting a hardship determination. Submit your completed form and letter to us.

How long does a VA FOIA request take?

Under the law, all federal agencies are required to respond to a FOIA request within 20 business days, unless there are “unusual circumstances.” The time period generally begins when the request is received by the FOIA office within the VA that maintains the records sought.

What is the VA Form 22 5495?

Use VA Form 22-5495 to request changes to your education benefits if you're using one of these programs: Survivors' and Dependents' Educational Assistance (DEA) program, or. Fry Scholarship.

Where do I get a VA Dbq form?

Resources and support. Call us. 800-698-2411. Visit a medical center or regional office. Find a VA location.

What VA form is used for dependents?

Use VA Form 21-686c to submit a claim for additional benefits for a dependent, or to request to remove a dependent from your benefits.

What forms are required for VA aid and attendance?

Use VA Form 21-2680 to apply for Aid and Attendance benefits that will be added to your monthly compensation or pension benefits.

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What is VA 10-5345?

VA Form 10-5345 is a form used by veterans and veterans' dependents to authorize the release of their health information to third parties.

Who is required to file VA 10-5345?

Veterans and their dependents who wish to authorize the release of their health information to a designated individual or entity are required to file VA 10-5345.

How to fill out VA 10-5345?

To fill out VA 10-5345, complete the sections with your personal information, specify the recipient of the health information, and sign the form to authorize the release.

What is the purpose of VA 10-5345?

The purpose of VA 10-5345 is to provide a legal authorization for the Department of Veterans Affairs to disclose a veteran's health information to specified individuals or organizations.

What information must be reported on VA 10-5345?

Information that must be reported on VA 10-5345 includes the veteran's name, social security number, the name of the individual or entity receiving the information, and the specific health information being released.