Free VA Form 10-5345a - Individuals' Request for a Copy of Their Own Health Information - fill - Federal


File Size: 774.5 kB
Pages: 1
Date: April 18, 2006
File Format: PDF
State: Federal
Category: Veterans Forms
Word Count: 352 Words, 2,115 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.va.gov/vaforms/medical/pdf/vha-10-5345a-fill.pdf

Download VA Form 10-5345a - Individuals' Request for a Copy of Their Own Health Information - fill ( 774.5 kB)


Preview VA Form 10-5345a - Individuals' Request for a Copy of Their Own Health Information - fill
OMB Number: 2900-0260 Estimated Burden: 2 minutes

INDIVIDUALS' REQUEST FOR A COPY OF THEIR OWN HEALTH INFORMATION
PRIVACY ACT AND PAPERWORK 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 it 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 the form. 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 Veterans Affairs (VA) in accordance with 38 CFR 1.577. The information on this form is requested under Title 38, U.S.C. 501. Your disclosure of the information requested on this form is voluntary. However, if the information including Social Security Number (SSN) (the SSN will be used 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 affect on any other benefits to which you may be entitled.
VETERAN'S LAST NAME- FIRST NAME- MIDDLE INTIAL SOCIAL SECURITY NO. DATE OF BIRTH

Check applicable box(es) and state the extent or nature of information to be copied/printed, giving the dates or approximate dates covered by each

DESCRIPTION OF INFORMATION REQUESTED

FACILITY WHERE TREATED:

DATES OF TREATMENT:

COPY OF HOSPITAL SUMMARY

COPY OF OUTPATIENT TREATMENT NOTE(S)

OTHER (Specify)

COPY OF HEALTH INFORMATION IS TO BE DELIVERED TO THE INDIVIDUAL
IN-PERSON BY MAIL, TO ADDRESS BELOW (include City, State & ZIP) PHONE NO.

PATIENT SIGNATURE

DATE (mm/dd/yyyy)

NOTE: If signed by someone other than the patient, indicate the authority (e.g., guardianship or power of attorney) under which request is made.
VA FORM MAY 2005

10-5345a