Va Form 10 5345 PDF Details

The VA Form 10 5345 is a document that is used to request disability compensation from the Veterans Administration. This form can be filled out by veterans who are looking to receive benefits for conditions that are related to their military service. The 10 5345 form can be complicated, so it is important to understand what information is required before you begin filling it out. In this blog post, we will provide an overview of the VA Form 105345 and explain how to complete it correctly. We will also highlight some of the benefits that may be available to veterans who submit a completed 10 5345 form.

The table holds specifics of the va form 10 5345. It's worth finding the time to study this before starting submitting your document.

QuestionAnswer
Form NameVa Form 10 5345
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names

Form Preview Example

REQUEST FOR AND AUTHORIZATION TO

RELEASE HEALTH INFORMATION

PRIVACY ACT AND PAPER WORK 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 is 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 the instructions, gather the necessary facts and fill out this form. 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 information needed 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 the provision of treatment, payment, enrollment in the VA Health Care Program, or eligibility for benefits on the signing of an authorization, except for research-related treatment where an authorization for the use or disclosure of individually- identifiable health information for such research is required. 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 system of records notices identified as 24VA10A7 "Patient Medical Record - VA", 08VA05 "Employee Medical File System Records (Title 38)-VA" and in accordance with the Notice of Privacy Practices. VA may also use this information to identify Veterans and person 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 VA Health Care Facility)

LAST NAME- FIRST NAME- MIDDLE NAME

DATE OF BIRTH (mm/dd/yyyy)

PATIENT'S MAILING ADDRESS (including City, State and Zip Code)

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

PURPOSE(S) OR NEED: Information is to be used by the requestor for:

TREATMENT

BENEFITS

LEGAL

EMPLOYMENT

OTHER (Please specify)

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

HEALTH SUMMARY (Prior 2 Years)

INPATIENT DISCHARGE SUMMARY (Dates):

PROGRESS NOTES:

SPECIFIC CLINICS (Name & Date Range):

SPECIFIC PROVIDERS (Name & Date Range):

DATE RANGE:

OPERATIVE/CLINICAL PROCEDURES (Name & Date):

LAB RESULTS:

SPECIFIC TESTS (Name & Date):

DATE RANGE:

RADIOLOGY REPORTS (Name & Date):

LIST OF ACTIVE MEDICATIONS:

FLU VACCINATION (Dose, Lot Number, Date & Location):

OTHER (Describe):

VA FORM

10-5345

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DEC 2020

LAST NAME- FIRST NAME- MIDDLE NAME

DATE OF BIRTH (mm/dd/yyyy)

SENSITIVE DIAGNOSES: REVIEW AND, IF APPROPRIATE, COMPLETE WHEN RELEASE IS FOR ANY PURPOSE OTHER THAN TREATMENT.

I request and authorize Department of Veterans Affairs to release the information pertaining to the condition(s) below for the non-treatment purpose(s) listed in this authorization.

DRUG ABUSE

ALCOHOLISM OR ALCOHOL ABUSE

SICKLE CELL ANEMIA

HUMAN IMMUNODEFICIENCY VIRUS (HIV)

I understand that information on these sensitive diagnoses may be released for treatment purposes without me checking the above boxes, and will be released even if the boxes are unchecked unless I indicate by checking the box below that I do not want this information released for this specific disclosure.

I do not want sensitive diagnoses released for treatment purposes under this specific authorization. I realize this does not impact other future requests unrelated to this authorization.

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.

EXPIRATION: Without my express revocation, the authorization will automatically expire (select one of the following):

AFTER ONE-TIME DISCLOSURE, IF ALL NEEDS ARE SATISFIED

ON (mm/dd/yyyy)(enter a future date other than date signed by patient)

UNDER THE FOLLOWING CONDITION(S):

PATIENT SIGNATURE (Sign in ink)

DATE (mm/dd/yyyy)

LEGAL REPRESENTATIVE SIGNATURE (if applicable) (Sign in ink)

DATE (mm/dd/yyyy)

PRINT NAME OF LEGAL REPRESENTATIVE

RELATIONSHIP TO PATIENT

FOR VA USE ONLY

TYPE AND EXTENT OF MATERIAL RELEASED

DATE RELEASED (mm/dd/yyyy)

RELEASED BY:

VA FORM 10-5345, DEC 2020

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