Va Form 10-5345 - Request For And Authorization To Release Health Information
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REQUEST FOR AND AUTHORIZATION TO
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.
(Name and Address of VA Health Care Facility)
TO: DEPARTMENT OF VETERANS AFFAIRS
CAPT James A. Lovell FHCC
3001 Greenbay Rd.
North Chicago IL. 60064
LAST NAME- FIRST NAME- MIDDLE INITIAL
LAST 4 SSN
DATE OF BIRTH
NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL, OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED
Masonic Association of Service and Therapy Dogs C/O Jay Reed
1715 Cherry Court, Lake Villa, IL. 60046
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
SICKLE CELL ANEMIA
(HIV)
ALCOHOLISM OR ALCOHOL ABUSE
TESTING FOR OR INFECTION WITH HUMAN IMMUNODEFICIENCY VIRUS
DESCRIPTION OF INFORMATION REQUESTED
Check applicable box(es) and state the extent or nature of information to be provided:
(Prior 2 Years)
HEALTH SUMMARY
(Dates)
INPATIENT DISCHARGE SUMMARY
:
PROGRESS NOTES:
(Name & Date Range)
SPECIFIC CLINICS
:
(Name & Date Range)
SPECIFIC PROVIDERS
:
DATE RANGE:
(Name & Date)
OPERATIVE/CLINICAL PROCEDURES
:
LAB RESULTS:
(Name & Date)
SPECIFIC TESTS
:
DATE RANGE:
(Name & Date)
RADIOLOGY REPORTS
:
LIST OF ACTIVE MEDICATIONS
(Describe)
OTHER
:
PURPOSE(S) OR NEED
Information is to be used by the individual for:
(Specify below)
TREATMENT
BENEFITS
LEGAL
OTHER
VA FORM
10-5345
Page 1 of 2
JUN 2017
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