VA Form 10-5345 Printable, Fillable in PDF

VA Form 10-5345 Printable, Fillable in PDF – This document is used to get a veteran’s written and signed authorization to distribute their medical information following the Health Insurance Portability and Accountability Act (HIPAA). The Department of Veterans Affairs (VA) of the United States of America may also use the information included in this document to identify persons who are claiming or receiving VA benefits.

VA Form 10-5345 Printable, Fillable in PDF

The most recent version of the form was made available to the public on September 1, 2018. Alternatively, you may get a current fillable version of the form by downloading it from the link provided below or by visiting the VA’s website. The Department of Veterans Affairs (VA) must receive your request before any person or organization may access or use your medical information for treatment, employment, legal, or other reasons. When claiming VA benefits, you must complete this form completely.

Other related forms include VA Form 10-5345A, Individuals’ Request for a Copy of Their Own Health Information, which can be used to request a copy of a health record maintained by the Department of Veterans Affairs, and VA Form 10-5345A-MHV, Individual’s Request for Med Record from MyHealtheVet, which can be used to request an electronic copy of a medical record through a MyHealtheVet account.

Instructions For Completing VA Form 10-5345

The following are the instructions for VA Form 10-5345:

  • The information included in the paper must be correct and full;
  • Although the provision of the information is entirely optional, VA will be unable to complete the request unless the last four digits of your Social Security number (SSN) and your date of birth are supplied;
  • An individual has the right to revoke their authorization at any moment.
  • It is essential to make a formal request to the appropriate authority to revoke the authorization. Revocations made verbally will not be accepted.
  • After you have completed and signed the VA Form 10-5345, you will be given a copy of the form to keep on file. It is necessary to retain a copy of this document for future reference; and
  • If you are unable to seek the release of medical records on your own, your legal agent may do so on your behalf.
  • The information given via this document may be shared again with the same recipient.

Detailed Instructions For Completing VA Form 10-5345

The document is just two pages in length. The majority of its fields are self-explanatory. The average amount of time required to finish the paper is around two minutes. The VA Form 10-5345 should be filled out in the following manner:

  • Fill out the form with the name and location of the VA medical institution.
  • Name and address of the organization or person to whom medical records are to be provided, as well as the reason for their release.
  • Make a clear statement about why information will be shared.
  • In the “Information Requested” box, provide the information that you want to make public or make available. To give specifics on the period and kind of material to be revealed, check the applicable boxes and enter the information in the corresponding fields.
  • If the medical data is being shared for reasons other than treatment, examine and complete the “Sensitive Diagnoses” portion of the form. Information about the diagnosis listed in this area will be shared with medical professionals for treatment reasons without your permission. If you do not want the information to be released, please tick the box below that says that you do not want this particular information to be shared with anybody.
  • Pay close attention to the authorization statement.
  • In the “Expiration” section, provide the date on which the permission will expire or the circumstances under which it will expire.
  • Sign and date the bottom of the form. Your legal representative may sign the document on your behalf.
  • The bottom of the form is intended only for use by VA employees.

Where Should VA Form 10-5345 Be Sent?

This form, which should be completed and signed, should be delivered to the individual VA health care institution where the veteran received treatment. For each VA healthcare facility where you need to share medical information about your treatment, you must submit a separate form to each facility where you get treatment.

VA Form 10-5345 Printable, Fillable in PDF

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