Fillable REQUEST FOR AND AUTHORIZATION TO RELEASE HEALTH INFORMATION (Arizona)

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REQUEST FOR AND AUTHORIZATION TO RELEASE HEALTH INFORMATION (Arizona)

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The REQUEST FOR AND AUTHORIZATION TO RELEASE HEALTH INFORMATION (Arizona) form is 2 pages long and contains:

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  • 27 check-boxes
  • 33 other fields

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10-5345
VA FORM
SEP 2018
Page 1 of 2
LAST 4 SSNLAST NAME- FIRST NAME- MIDDLE INITIAL
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 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. VA 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”, 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.
REQUEST FOR AND AUTHORIZATION TO
RELEASE HEALTH INFORMATION
HEALTH SUMMARY (Prior 2 Years)
LIST OF ACTIVE MEDICATIONS:
RADIOLOGY REPORTS (Name & Date):
DATE RANGE:
SPECIFIC TESTS (Name & Date):
LAB RESULTS:
OPERATIVE/CLINICAL PROCEDURES (Name & Date):
DATE RANGE:
SPECIFIC PROVIDERS (Name & Date Range):
SPECIFIC CLINICS (Name & Date Range):
PROGRESS NOTES:
INPATIENT DISCHARGE SUMMARY (Dates):
TO: DEPARTMENT OF VETERANS AFFAIRS (Name and Address of VA Health Care Facility)
NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL, OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED
FLU VACCINATION (Dose, Lot Number, Date & Location):
DATE OF BIRTH
INFORMATION REQUESTED: Check applicable box(es) and state the extent or nature of information to be provided:
TREATMENT LEGAL EMPLOYMENTBENEFITS
PURPOSE(S) OR NEED:
Information is to be used by the individual for:
OTHER (Describe):
OTHER (Please specify)
FOR VA USE ONLY
DATE (mm/dd/yyyy)PATIENT SIGNATURE (Sign in ink)
AFTER ONE-TIME DISCLOSURE, IF ALL NEEDS ARE SATISFIED
ON
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.
(enter a future date other than date signed by patient)
DATE (mm/dd/yyyy)LEGAL REPRESENTATIVE SIGNATURE (if applicable) (Sign in ink)
PRINT NAME OF LEGAL REPRESENTATIVE RELATIONSHIP TO PATIENT
TYPE AND EXTENT OF MATERIAL RELEASED
DATE RELEASED RELEASED BY:
LAST 4 SSNLAST NAME- FIRST NAME- MIDDLE INITIAL DATE OF BIRTH
VA FORM 10-5345, SEP 2018
Page 2 of 2
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.
SENSITIVE DIAGNOSES: REVIEW AND, IF APPROPRIATE, COMPLETE WHEN RELEASE IS FOR ANY PURPOSE
OTHER THAN TREATMENT.
DRUG ABUSE
ALCOHOLISM OR ALCOHOL ABUSE
SICKLE CELL ANEMIA
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.
HUMAN IMMUNODEFICIENCY VIRUS (HIV)
UNDER THE FOLLOWING CONDITION(S):
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.
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REQUEST FOR AND AUTHORIZATION TO RELEASE HEALTH INFORMATION (Arizona)

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Completed 20 July 2020

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