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Get CA VA Northern California Health Care System Health History Form 2010-2024
First name: Last 4 SS#: Date of birth: ALLERGIC REACTIONS Allergen Initial Reaction Date Reactions CHILDHOOD DISEASES / INFECTIOUS DISEASES Have you had: Mumps Measles Rubella (German measles) Varicella (Chicken pox) Tuberculosis Hepatitis A Hepatitis B Hepatitis C Yes No Unk Comments No Unk Comments VACCINES / IMMUNIZATIONS / SKIN TESTS Have you had: MMR (Mumps, Measles, Rubella) Varicella (Chick.
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Edna FAQ
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Authorization to disclose information to the Department of Veterans Affairs (VA) (VA Forms 21-4142 and 21-4142a) Complete this form if you want to give us permission to request your records from a non-VA source to support your benefit claim. Authorize The Release Of Non-VA Medical Information To VA - VA.gov va.gov https://.va.gov › supporting-forms-for-claims › rele... va.gov https://.va.gov › supporting-forms-for-claims › rele...
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REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR. DISABILITY BENEFITS. OMB Control No.
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The form authorizes release of information in ance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164; 5 U.S.C. VA Form 10-5345 va.gov https://.va.gov › pdf › va_form_10-5345_fillable va.gov https://.va.gov › pdf › va_form_10-5345_fillable
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If you'd like our help gathering your private medical records, you'll need to give us permission to get them. Fill out an Authorization to Disclose Information to the Department of Veterans Affairs (VA Form 21-4142). You can submit this form online. Or you can download it and submit by mail.
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Use this form to provide your written authorization to obtain your treatment records, so the VA can get the information required to process your claim.
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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. Medical Records Office | VA Greater Los Angeles Health Care - VA.gov va.gov https://.va.gov › greater-los-angeles-health-care › m... va.gov https://.va.gov › greater-los-angeles-health-care › m...
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Use VA Form 10-10EZ if you're a Veteran and want to apply for VA health care. You must be enrolled in VA health care to get care at VA health facilities or to have us cover your care at a community care provider (an approved non-VA provider). About VA Form 10-10EZ | Veterans Affairs va.gov https://.va.gov › find-forms › about-form-10-10ez va.gov https://.va.gov › find-forms › about-form-10-10ez
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VA Form 21-4142, is used to authorize the disclosure of information to the Department of Veterans Affairs (VA). VA Form 21-4142a, is used to gather private provider information from the claimant to the VA. Without this information, determination of entitlement would not be possible.
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