» » Veterans Affairs Request for and Authorization to Release Medical Records or Health Information (VA Form 10-5345)

Veterans Affairs Request for and Authorization to Release Medical Records or Health Information (VA Form 10-5345)

The Veterans Affairs Request for and Authorization to Release Medical Records or Health Information, or “VA Form 10-5345”, is a document that will allow the collection of treatment records for doctors or any health care provider, once their active duty is completed if they have ever been treated at any Veteran’s Facility anywhere.

How to Write

Step 1 – The applicant must download the document – Read the Privacy Act and  Paper reduction section.

Step 2 – Patient Information – Enter the following:

  • Print or type the name and address of the VA care facility
  • Patient’s last name, first name, middle initial
  • Patient’s Social Security Number
  • Type or print the address and name of the organization, individual (title if any) to whom information shall be released

Step 3 – Veteran’s Request –

  • Read the information in this box
  • Check and date the applicable boxes

Information Requested –

  • Check the applicable boxes in this section
  • Provide dates covered by each
  • Specify the purposes for the information to be used by whomever shall request the release of information in the field provided

Step 4 – Authorization – Applicant must carefully read this section:

  • If any additional information will be provided, enter the date the information is being provided into the small  field in the paragraph
  • In the larger field, enter all of the required information

Step 5 – Signature –

  • Prior to provision of signature, the applicant must review the Practitioner’s Opinions and Statements section
  • Date the signature in mm/dd/yyyy format in the date box
  • Submit the signature of the person authorized to sign for the patient (Attach Power of Attorney (POA) if required)

The remainder of the document is for Veteran’s Administration Use Only ( Document Complete)

 


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