VA Form 10-5345a-M Individuals' Request for a Copy of Their Own Health Info

OMB Number: 2900-XXXX
Estimated Burden: 3 minutes

INDIVIDUALS' REQUEST FOR A COPY OF THEIR OWN
HEALTH INFORMATION -My HealtheVet (MHV)
PRIVACY ACT AND PAPERWORK REDUCTION ACT INFORMATION

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with
the clearance requirements of section 3507 of the Act. We may not conduct or sponsor, and you are not required to
respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by
all individuals who must complete this form will average 3 minutes. This includes the time it will take to read the
instructions, gather the necessary facts and fill out the form. 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 Veterans Affairs (VA)
in accordance with 38 CFR 1.577.
The information on this form is requested under Title 38, U.S.C. 501. Your disclosure of the information requested on
this form is voluntary. However, if the information including Social Security Number (SSN) (the SSN will be used to
locate records for release) is not furnished completely and accurately, VA will be unable to comply with the request.
Failure to furnish the information will not have any affect on any other benefits to which you may be entitled.
VETERAN'S LAST NAME- FIRST NAME- MIDDLE INTIAL

DATE OF BIRTH

SOCIAL SECURITY NO.

DESCRIPTION OF INFORMATION REQUESTED

Check applicable box(es) and state the extent or nature of information to be copied/printed, giving the dates or approximate dates covered by each

FACILITY WHERE TREATED:

X COPY OF HOSPITAL SUMMARY

DATES OF TREATMENT:

X COPY OF OUTPATIENT TREATMENT NOTE(S)

X

OTHER (Specify)

I request all available electronic personal health records through My
HealtheVet.

COPY OF HEALTH INFORMATION IS TO BE DELIVERED TO THE INDIVIDUAL
X IN-PERSON

BY MAIL, TO ADDRESS BELOW (include City, State & ZIP)

PHONE NO.

I request access to all available electronic health information via My
HealtheVet (MHV) account. All prerequisites for In-Person Authentication
have been satisfied, including MHV training.

PATIENT SIGNATURE

DATE (mm/dd/yyyy)

NOTE: If signed by someone other than the patient, indicate the authority (e.g., guardianship or power of attorney) under which request is made.
VA FORM
AUG 2009

10-5345a-MHV

INDIVIDUALS' REQUEST FOR A COPY OF THEIR OWN HEALTH INFORMATION, CONTINUED
What is My HealtheVet?
My HealtheVet is an online environment where veterans, family, and clinicians may come together to optimize a
veteran's health. Veterans are able to access a single source of trusted health information, one stop shopping for VA
benefits, a health calendar, self-enter health insurance information, medical events, labs, medications, over the counter
(OTC) and supplements, allergies and immunizations, Military Health History, and nine health trackers (e.g., blood
pressure, blood sugar, weight, temperature, cholesterol, pain level). You are able to refill prescriptions online and track
information in food and activity journals and personal and family health histories as part of the Personal Health Record.
My HealtheVet offers the first condition centers and healthy living centers and releases copies of key portions of health
information contained in VA's electronic health record. My HealtheVet is a Personal Health Record owned and
controlled by you.
To Upgrade a My HealtheVet Account
As part of the My HealtheVet security measures, you will be asked to verify your identify in person at a VA hospital or
Community Based Outpatient Clinic. The release of information staff will ask you to show a valid Veterans Identification
Card or form of identification with a picture, review and sign a request to upgrade your My HealtheVet account, and view
an orientation video.
Accessing Copies of Key Portions of Your VA Health Record
You will be able to view copies of key portions of your VA health record. This will better enable you to monitor and
protect your health. You can also print a summary of your Personal Health Record and share it with your VA and non-VA
provider to improve the level of care they provide you. The requested health information will be forwarded to your
account after an initial delay to provide time for your healthcare provider to review the information and allow personal
communication with you on occasion.
Privacy and Security
All information placed in your My HealtheVet account becomes a part of your Personal Health Record. It is not
distributed, shared or viewed by the VA, and all privacy and security information listed in the My HealtheVet website
terms and conditions still apply. It is important to remember that you also have a responsibility in keeping your health
information safe.
Here are a few tips for protecting your privacy:
You will be able to access your My HealtheVet account by logging in anywhere there's Internet access, including
public places like libraries. When you log on to My HealtheVet, remember that people may see your personal
information on the screen. Turn the screen away from their view. Don't walk away from the computer with your
information showing. And always remember to log off when you have finished.
Don't share your user ID and password with anyone. Writing them down is a good idea, but keep them in a safe place,
such as a wallet or purse. You may want to print copies of your Personal Health Record to take with you on trips or visits
to providers. Be careful not to leave printed material in any public places and store copies in a safe place, like a locked
file cabinet. If you share your Personal Health Record with others, VA has no authority to ensure these people protect
your privacy. Be careful of who you give copies of your Personal Health Record. If you print updated copies of your
Personal Health Record, be sure to destroy your old copies, preferably with a shredder.
My Privacy Rights
Veterans who are enrolled for VA health care benefits are afforded various privacy rights under Federal law and
regulations including the right to a notice of privacy practices. The VA Notice of Privacy Practices provides enrolled
veterans with information on how VHA may use and disclose your personal health information. The Notice also advises
enrolled veterans of their rights to know when and to whom their health information may have been disclosed; request
access to or receive a copy of their health information on file with VA; request an amendment to correct inaccurate
information on file; and file a privacy complaint. A copy of the VA Notice of Privacy Practices, IB 10-163, may be
obtained through the Internet at http://www1.va.gov/Health_Benefits or through the mail by writing the VHA Privacy
Office (19F2), 810 Vermont Avenue NW, Washington, DC 20420.
VA FORM
AUG 2009

10-5345a-MHV