This form is a business type form that is formatted to allow you to complete the form using Adobe Acrobat or Word. The word files have been formatted to allow completion by entry into fields. Some of the forms under this category are rather simple while others are more complex. The formatting is worth the small cost.
Virginia Fax Transmittal Form
Category:
State:
Multi-State
Control #:
US-141-AZ
Format:
Word;
PDF;
Rich Text
Instant download
Description
How to fill out Fax Transmittal Form?
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FAQ
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.
PATIENT SIGNATURE (Sign in ink) SAME ADDRESS AS ABOVE NEW ADDRESS BELOW IN-PERSON PICK-UP, PROVIDE CONTACT PHONE NUMBER: 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 Veteran Affairs (VA) in ance with 38 CFR ...
You'll need to fill out an Individuals' Request for a Copy of Their Own Health Information (VA Form 10-5345a). Submit your completed form to your VA health facility's medical records office. This office is also called a Release of Information Office. You can submit your form by mail, by fax, or in person.
Fill out a Claim for Payment of Cost of Unauthorized Medical Services (VA Form 10-583). For prescription claims, include this information on the form: The name and address of the pharmacy. The name of the prescribing provider.
VA forms are available at .va.gov/vaforms. IMPORTANT: Please read the Privacy Act and Respondent Burden on Page 14 before completing the form.
Use VA Form 21-0845 to authorize VA to share your personal information with a non-VA (third-party) individual or organization.
