Va Form 10 5345A PDF Details

Are you looking for a way to manage your finances more effectively? If so, the VA Form 10 5345A might be something that you should consider. This form can help you track your expenses and make sure that your finances are in order. In this blog post, we will discuss what the VA Form 10 5345A is and how it can help you manage your finances. We will also provide some tips on how to fill out the form correctly.

Here's some information that may help you establish just how long you will need to complete the va form 10 5345a.

QuestionAnswer
Form NameVa Form 10 5345A
Form Length1 pages
Fillable?Yes
Fillable fields1
Avg. time to fill out27 sec
Other names

Form Preview Example

INDIVIDUALS' REQUEST FOR A COPY

OF THEIR OWN HEALTH INFORMATION

PRIVACY ACT INFORMATION

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 Veteran Affairs (VA) in accordance with 38 CFR 1.577. The information on this form is requested under Title 38 U.S.C. 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. Failure to furnish the information will not have any effect on any other benefits to which you may be entitled.

TO: DEPARTMENT OF VETERANS AFFAIRS (Name and Location of the 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)

DESCRIPTION OF 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

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

LEGAL HEALTH RECORDS FOR TORTS:

OTHER (Describe):

COPY OF HEALTH INFORMATION IS TO BE DELIVERED TO THE INDIVIDUAL

PAPER

CD-ROM

OTHER:

 

 

 

IN-PERSON PICK-UP, PROVIDE CONTACT PHONE NUMBER:

 

MAIL TO:

SAME ADDRESS AS ABOVE

NEW ADDRESS BELOW

PATIENT SIGNATURE (Sign in ink)

DATE (mm/dd/yyyy)

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

VA FORM

10-5345a

Page 1 of 1

JUL 2021

How to Edit Va Form 10 5345A Online for Free

The PDF editor was designed to be so simple as it can be. Since you comply with the following steps, the procedure for creating the Va Form 10 5345A form is going to be easy.

Step 1: Click the button "Get Form Here".

Step 2: Now you may enhance your Va Form 10 5345A. You may use our multifunctional toolbar to include, remove, and change the text of the form.

The PDF form you are about to complete will consist of the following segments:

stage 1 to writing Va Form 10 5345A

Type in the requested information in the section RADIOLOGYREPORTSNameDate, LISTOFACTIVEMEDICATIONS, LEGALHEALTHRECORDSFORTORTS, OTHERDescribe, PAPER, CDROM, OTHER, MAILTO, SAMEADDRESSASABOVE, NEWADDRESSBELOW, PATIENTSIGNATURESigninink, DATEmmddyyyy, VAFORMJUL, and Pageof.

Filling in Va Form 10 5345A stage 2

Step 3: Click "Done". Now you can export the PDF form.

Step 4: Generate copies of your form. This should save you from possible future issues. We cannot look at or reveal your information, thus be sure it is safe.

Watch Va Form 10 5345A Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .