VA Form 10-5345: Request for and Authorization to Release Health Information
VA Form 10-5345 authorizes VA to share your protected health information with a person or organization outside VA, such as a private doctor, attorney, insurer, or family member.
This is the genuine VA PDF, unmodified. Source: VA official page.
What is VA Form 10-5345?
Federal privacy laws prevent VA from releasing your medical records to third parties without your written authorization. VA Form 10-5345 is that authorization. It names who may receive the records, what information is covered, and for what purpose.
The form includes specific checkboxes for especially protected categories, such as records relating to drug or alcohol treatment, HIV, and sickle cell anemia, which are only released if you explicitly authorize them. You can revoke the authorization in writing at any time, except to the extent VA has already acted on it.
Who files VA Form 10-5345?
- Veterans who want VA to send records to a private physician or outside hospital
- Veterans authorizing release to an attorney, insurer, or benefits representative
- Veterans allowing a family member or caregiver to receive their health information
- Patients of VA facilities directing records to any other named third party
How to fill out VA Form 10-5345
- Identify exactly who should receive the records and gather their full name and address.
- Complete your identifying information and name the recipient in the release section.
- Describe the information to be released and the date ranges, and check the boxes for any specially protected categories you want included.
- State the purpose of the release and any expiration date or event for the authorization.
- Sign and date the form, then submit it to the Release of Information office at the VA health facility that holds your records.
Quick fill VA Form 10-5345 on this page
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Frequently asked questions
Can I cancel the authorization after I sign it?
Yes. You may revoke it in writing at any time by notifying the facility holding your records. Revocation does not undo disclosures VA already made while the authorization was valid.
Is this the right form to get my own records?
No. Use VA Form 10-5345a to request a copy of your own health information. The 10-5345 is for authorizing release to someone other than yourself.