This form is used to inform the plaintiff's medical provider that an attorney has been retained by plaintiff and that plaintiff authorizes the release to attorney of all of his or her medical records.
Virginia Authorization for Medical Information
State:
Multi-State
Control #:
US-PI-0244
Format:
Word;
Rich Text
Instant download
Description
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How to fill out Authorization For Medical Information?
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FAQ
Use VA Form 10-5345 to authorize us to share your health information with a non-VA (or third-party) individual or organization.
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.
An authorization gives the non-VA provider authority to provide health care to the Veteran patient, and provides assurance of payment for those services. The authorization document binds VA to the language that is included on the authorization.
When to use this form. Use VA Form 21-4142a to give us permission to get medical provider information from a non-VA source like a private doctor or hospital. This will allow us to gather information like the name and address of a facility and your medical treatment dates.
A Privacy Rule Authorization is an individual's signed permission to allow a covered entity to use or disclose the individual's protected health information (PHI) that is described in the Authorization for the purpose(s) and to the recipient(s) stated in the Authorization.
Use VA Form 21-4142 to give us permission to obtain your personal information from a non-VA source like a private doctor or hospital. Examples of personal information may include your medical treatment, hospitalizations, psychotherapy, or outpatient care.
Use VA Form 21-4142 to give us permission to obtain your personal information from a non-VA source like a private doctor or hospital. Examples of personal information may include your medical treatment, hospitalizations, psychotherapy, or outpatient care.
When to use this form. Use VA Form 21-4142a to give us permission to get medical provider information from a non-VA source like a private doctor or hospital. This will allow us to gather information like the name and address of a facility and your medical treatment dates.