Get VA 10-5345 2020-2023

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 no longer be protected. Without my express revocation the authorization will automatically expire 1 upon satisfaction of the need for disclosure 2 on date supplied by patient 3 under the following condition s I understand that the VA health care practitioner 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. 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 Social Security Number SSN the SSN will be used to locate records for release is not furnished completely and accurately Department of Veterans Affairs 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. You do not have to provide the information to VA but if you don t VA will be unable to process your request and serve your medical needs. Failure to furnish the information will not have any affect on any other benefits to which you may be entitled. If you provide VA your Social Security Number VA will use it to administer your VA benefits. VA may also use this information to identify veterans and persons claiming or receiving VA benefits and their records and for other purposes authorized or required by law. VA may make a routine use disclosure of the information as outlined in the Privacy Act systems of records notices identified as 24VA10P2 Patient Medical Record - VA and in accordance with the Notice of Privacy Practices. You do not have to provide the information to VA but if you don t VA will be unable to process your request and serve your medical needs. Failure to furnish the information will not have any affect on any other benefits to which you may be entitled. If you provide VA your Social Security Number VA will use it to administer your VA benefits. 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 systems of records notices identified as 24VA10P2 Patient Medical Record - VA and in accordance with the Notice of Privacy Practices. You do not have to provide the information to VA but if you don t VA will be unable to process your request and serve your medical needs. 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 Department of Veterans Affairs 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 systems of records notices identified as 24VA10P2 Patient Medical Record - VA and in accordance with the Notice of Privacy Practices. OMB Number 2900-0260 Estimated Burden 2 minutes REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL RECORDS OR HEALTH INFORMATION Privacy Act and Paperwork Reduction Act Information 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.