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Va Form 10-0400 - Request For Veterans Service Organization (Vso) Access To Computer Patient Record System (Cprs)

REQUEST FOR VETERANS SERVICE ORGANIZATION (VSO)

ACCESS TO COMPUTER PATIENT RECORD SYSTEM (CPRS)

READ ONLY

To request access to CPRS Read Only in order to assist a veteran in the preparation of the veteran's claim,

complete Section 1 and submit the form to the Chief, Health Information Management. A single completed

form is necessary for each veteran for whom you hold Power of Attorney (POA). This form will be filed in the

veteran's administrative record.

SECTION 1 (to be completed by the VSO requesting access)

NAME OF REPRESENATIVE

ORGANIZATION

NAME OF VETERAN

SIGNATURE

DATE

SECTION 2 (to be completed by the Chief, Health Information Management, or designee)

I have verified that:

The requestor is a representative of an officially-recognized Veterans Service Organization and is

s s

accredited in accordance with Title 38 United States Code (U.S.C.) 14.626-14.635.

The requestor holds valid POA for the veteran listed in Section 1.

DATE

SIGNATURE AND TITLE

NOTE: This form must be filed in the veteran's administrative record, along with a copy of the POA and will

serve as documentation of the initial disclosure of information.

ADDITIONAL COMMENTS

10-0400

VA FORM

JUL 2002

Va Form 10-0400 - Request For Veterans Service Organization (Vso) Access To Computer Patient Record System (Cprs)