VA Form 10-5345 Request for and Authorization to Release Medical Records

OMB Number: 2900-0260
Estimated Burden: 2 minutes

REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL
RECORDS OR HEALTH INFORMATION
Privacy Act and Paperwork Reduction 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 Social Security Number (SSN) (the SSN will be used to locate records for release) is not furnished completely and accurately, Department of Veterans Affairs 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. VA may make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records notices identified as 24VA19 “Patient
Medical Record - VA” and in accordance with the VHA Notice of Privacy Practices. You do not have to provide the information to VA, but if you don't, VA will be unable to process your
request and serve your medical needs. Failure to furnish the information will not have any affect on any other benefits to which you may be entitled. If you provide VA your Social Security
Number, VA will use it to administer your VA benefits. 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. 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 Paperwork Reduction Act of 1995. 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 2 minutes. This includes the time it will take to read instructions, gather the
necessary facts and fill out the form.

ENTER BELOW THE PATIENT'S NAME AND SOCIAL SECURITY NUMBER IF THE PATIENT DATA CARD IMPRINT IS NOT USED.
TO: DEPARTMENT OF VETERANS AFFAIRS (Print or type name and address of health
care facility)

PATIENT NAME (Last, First, Middle Initial)

SOCIAL SECURITY NUMBER

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

VETERAN'S REQUEST: 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):
ALCOHOLISM OR ALCOHOL ABUSE

DRUG ABUSE

TESTING FOR OR INFECTION WITH HUMAN IMMUNODEFICIENCY VIRUS (HIV)

SlCKLE CELL ANEMIA

INFORMATION REQUESTED (Check applicable box(es) and state the extent or nature of the information to be disclosed, giving the dates or
approximate dates covered by each)
COPY OF HOSPITAL SUMMARY

COPY OF OUTPATIENT TREATMENT NOTE(S)

OTHER (Specify)

PURPOSE(S) OR NEED FOR WHICH THE INFORMATION IS TO BE USED BY INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED

NOTE: ADDITIONAL ITEMS OF INFORMATION DESIRED MAY BE LISTED ON THE BACK OF THIS FORM

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 the records. Redisclosure of my medical records by those receiving the above authorized
information may be accomplished without my further written authorization and may no longer be protected. Without my express revocation, the
authorization will automatically expire: (1) upon satisfaction of the need for disclosure; (2) on
(date supplied by patient); (3)
under the following condition(s):

I understand that the VA health care practitioner'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.
DATE

SIGNATURE OF PATIENT OR PERSON AUTHORIZED TO SIGN FOR PATIENT (Attach authority to sign, e.g., POA)

FOR VA USE ONLY
IMPRINT PATIENT DATA CARD (or enter Name, Address, Social Security Number)

TYPE AND EXTENT OF MATERIAL RELEASED

DATE RELEASED

VA FORM
MAY 2005

10-5345

RELEASED BY

USE EXISTING STOCK OF VA FORM 10-5345, DATED NOV 2004.

SSA COPY

OMB Number: 2900-0260
Estimated Burden: 2 minutes

REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL
RECORDS OR HEALTH INFORMATION
Privacy Act and Paperwork Reduction 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 Social Security Number (SSN) (the SSN will be used to locate records for release) is not furnished completely and accurately, Department of Veterans Affairs 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. VA may make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records notices identified as 24VA19 “Patient
Medical Record - VA” and in accordance with the VHA Notice of Privacy Practices. You do not have to provide the information to VA, but if you don't, VA will be unable to process your
request and serve your medical needs. Failure to furnish the information will not have any affect on any other benefits to which you may be entitled. If you provide VA your Social Security
Number, VA will use it to administer your VA benefits. 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. 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 Paperwork Reduction Act of 1995. 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 2 minutes. This includes the time it will take to read instructions, gather the
necessary facts and fill out the form.

ENTER BELOW THE PATIENT'S NAME AND SOCIAL SECURITY NUMBER IF THE PATIENT DATA CARD IMPRINT IS NOT USED.
TO: DEPARTMENT OF VETERANS AFFAIRS (Print or type name and address of health
care facility)

Veterans Health Administration

PATIENT NAME (Last, First, Middle Initial)

SOCIAL SECURITY NUMBER

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

Department of Veterans Affairs, Veterans Health Administration
VETERAN'S REQUEST: 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):
DRUG ABUSE

ALCOHOLISM OR ALCOHOL ABUSE

TESTING FOR OR INFECTION WITH HUMAN IMMUNODEFICIENCY VIRUS (HIV)

SlCKLE CELL ANEMIA

INFORMATION REQUESTED (Check applicable box(es) and state the extent or nature of the information to be disclosed, giving the dates or
approximate dates covered by each)
COPY OF HOSPITAL SUMMARY

COPY OF OUTPATIENT TREATMENT NOTE(S)

OTHER (Specify)

Pertinent health information from electronic health record including information created within 24 months
after the signature date of this authorization.
PURPOSE(S) OR NEED FOR WHICH THE INFORMATION IS TO BE USED BY INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED

To obtain information through the NwHIN for disability determination.
NOTE: ADDITIONAL ITEMS OF INFORMATION DESIRED MAY BE LISTED ON THE BACK OF THIS FORM

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 the records. Redisclosure of my medical records by those receiving the above authorized
information may be accomplished without my further written authorization and may no longer be protected. Without my express revocation, the
authorization will automatically expire: (1) upon satisfaction of the need for disclosure; (2) on
(date supplied by patient); (3)
under the following condition(s):

Two years from the date of signature.

I understand that the VA health care practitioner'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.
DATE

(mm/dd/yyyy)

SIGNATURE OF PATIENT OR PERSON AUTHORIZED TO SIGN FOR PATIENT (Attach authority to sign, e.g., POA)

FOR VA USE ONLY
IMPRINT PATIENT DATA CARD (or enter Name, Address, Social Security Number)

TYPE AND EXTENT OF MATERIAL RELEASED

DATE RELEASED

VA FORM
FEB 2012

10-5345 SSA

RELEASED BY

Authorization to Disclose Health Information to SSA Notice:
In order to process an Authorization to permit disclosure of your electronic health information to the Social
Security Administration (SSA) through the Nationwide Health Information Network (NwHIN) for disability
benefits, the Authorization must cover all types of health information, including information related to Human
Immunodeficiency Virus (HIV), sickle cell anemia, drug abuse and alcoholism or alcohol abuse. VA is unable
to remove HIV, sickle cell anemia, drug abuse and alcoholism or alcohol abuse information from your
electronic health record prior to it being sent to SSA.
All of the boxes for the four protected conditions, drug abuse, alcoholism or alcohol abuse, testing for
or infection with Human Immunodeficiency Virus (HIV), and sickle cell anemia under the VETERAN’S
REQUEST section have been checked for you. If you do not want to authorize the sharing of drug abuse,
alcoholism or alcohol abuse, HIV or sickle cell anemia, you should not complete this Authorization.
Even if you do not have any condition or information in your health record related to drug abuse, alcoholism
or alcohol abuse, HIV or sickle cell anemia at this time, this Authorization must include permission to disclose
this type of information. This means that if you acquire any of these conditions in the future, this Authorization
will allow VA to share that information. Your Authorization will be valid for 2 years from the date of signature
and will permit the disclosure of existing health information and health information created after you sign
this Authorization. This includes diagnosis of HIV or sickle cell anemia, and treatment for drug abuse and
alcoholism or alcohol abuse that occurs after the signature of this Authorization.
By completing this Authorization you are authorizing VA to share your electronic health information with
SSA through NwHIN for the purposes relating to obtaining disability benefits. VA will continue to share your
electronic health information through the NwHIN with SSA until this authorization expires (2 years from
signature) or you revoke it.

VA FORM
FEB 2012

10-5345 SSA