36C24418Q9641-005.pdf

Text

10-5345VA FORM

DEC 2017 Page 1 of 2

LAST 4 SSNLAST NAME- FIRST NAME- MIDDLE INITIAL

PRIVACY 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. However, if the information including the last four of your Social Security Number (SSN) and Date of Birth (used to locate records for release) is not furnished completely and accurately, VA 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. VHA may make a “routine use” disclosure of the information as outlined in the Privacy Act system of records notices identified as 24VA10P2 “Patient Medical Record – VA” and in accordance with the VHA Notice of Privacy Practices. 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.

REQUEST FOR AND AUTHORIZATION TO

RELEASE HEALTH INFORMATION

HEALTH SUMMARY (Prior 2 Years)

OTHER (Describe):

LIST OF ACTIVE MEDICATIONS

RADIOLOGY REPORTS (Name & Date):

DATE RANGE:

SPECIFIC TESTS (Name & Date):

LAB RESULTS:

OPERATIVE/CLINICAL PROCEDURES (Name & Date):

DATE RANGE:

SPECIFIC PROVIDERS (Name & Date Range):

SPECIFIC CLINICS (Name & Date Range):

PROGRESS NOTES:

INPATIENT DISCHARGE SUMMARY (Dates):

TO: DEPARTMENT OF VETERANS AFFAIRS (Name and Address of VA Health Care Facility)

NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL, OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED

DATE OF BIRTH

DESCRIPTION OF INFORMATION REQUESTED

I request and authorize Department of Veterans Affairs to release the information specified below to the organization, or individual named on this request. I understand that the information to be released includes information regarding the following condition(s):

VETERAN'S REQUEST

DRUG ABUSE

ALCOHOLISM OR ALCOHOL ABUSE

SICKLE CELL ANEMIA

HUMAN IMMUNODEFICIENCY VIRUS (HIV)

PURPOSE(S) OR NEED

TREATMENT OTHER (Specify below)LEGALBENEFITS

Information is to be used by the individual for:

Check applicable box(es) and state the extent or nature of information to be provided:

DATE (mm/dd/yyyy)PATIENT SIGNATURE (Sign in ink)

UNDER THE FOLLOWING CONDITION(S):

EXPIRATION

UPON SATISFACTION OF THE NEED FOR DISCLOSURE

ON

AUTHORIZATION

I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete to the best of my knowledge. I understand that I will receive a copy of this form after I sign it. I may revoke this authorization in writing, at any time except to the extent that action has already been taken to comply with it. Written revocation is effective upon receipt by the Release of Information Unit at the facility housing records.

Any disclosure of information carries with it the potential for unauthorized redisclosure, and the information may not be protected by federal confidentiality rules.

I understand that the VA health care provider’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. They may, however, be considered with other evidence when these decisions are made at a VA Regional Office that specializes in benefit decisions.

Without my express revocation, the authorization will automatically expire.

(enter a future date other than date signed by patient)

DATE (mm/dd/yyyy)LEGAL REPRESENTATIVE SIGNATURE (if applicable) (Sign in ink)

PRINT NAME OF LEGAL REPRESENTATIVE RELATIONSHIP TO PATIENT

FOR VA USE ONLY

TYPE AND EXTENT OF MATERIAL RELEASED

DATE RELEASED RELEASED BY:

LAST 4 SSNLAST NAME- FIRST NAME- MIDDLE INITIAL DATE OF BIRTH

VA FORM 10-5345, DEC 2017 Page 2 of 2

8.0.1291.1.339988.308172

REQUEST FOR AND AUTHORIZATION TO RELEASE HEALTH INFORMATION

VA Form 10-5345 Text 10-5345

VA FORM

DEC 2017

PRIVACY 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. However, if the information including the last four of your Social Security Number (SSN) and Date of Birth (used to locate records for release) is not furnished completely and accurately, VA 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. VHA may make a “routine use” disclosure of the information as outlined in the Privacy Act system of records notices identified as 24VA10P2 “Patient Medical Record – VA” and in accordance with the VHA Notice of Privacy Practices. 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.

REQUEST FOR AND AUTHORIZATION TORELEASE HEALTH INFORMATION

\\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg Department of Veterans Affairs Logo.

DESCRIPTION OF INFORMATION REQUESTED

I request and authorize Department of Veterans Affairs to release the information specified below to the organization, or individual named on this request. I understand that the information to be released includes information regarding the following condition(s):

VETERAN'S REQUEST

PURPOSE(S) OR NEED

Information is to be used by the individual for:

Check applicable box(es) and state the extent or nature of information to be provided:

EXPIRATION

AUTHORIZATION

I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete to the best of my knowledge. I understand that I will receive a copy of this form after I sign it. I may revoke this authorization in writing, at any time except to the extent that action has already been taken to comply with it. Written revocation is effective upon receipt by the Release of Information Unit at the facility housing records. Any disclosure of information carries with it the potential for unauthorized redisclosure, and the information may not be protected by federal confidentiality rules.

I understand that the VA health care provider’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. They may, however, be considered with other evidence when these decisions are made at a VA Regional Office that specializes in benefit decisions.

Without my express revocation, the authorization will automatically expire.

(enter a future date other than date signed by patient)

FOR VA USE ONLY

TYPE AND EXTENT OF MATERIAL RELEASED

VA FORM 10-5345, DEC 2017

RELEASE HEALTH INFORMATION. PRIVACY 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. However, if the information including the last four of your Social Security Number (SSN) and Date of Birth (used to locate records for release) is not furnished completely and accurately, VA 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. VHA may make a “routine use” disclosure of the information as outlined in the Privacy Act system of records notices identified as 24VA10P2 “Patient Medical Record – VA” and in accordance with the VHA Notice of Privacy Practices. 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. TO: DEPARTMENT OF VETERANS AFFAIRS (NAME AND ADDRESS OF V A. HEALTH CARE FACILITY).: