Free VA Form 10-0400 - Request for VSO Access to CPRS (Computer Patient Record System) - Federal

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 accredited in accordance with Title 38 United States Code (U.S.C.) s14.626-14.635. s The requestor holds valid POA for the veteran listed in Section 1.

SIGNATURE AND TITLE

DATE

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

VA FORM JUL 2002

10-0400