VA Form 10-5345

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VA Form 10-5345 is a medical records release form used to request the release of a veteran’s health information held by the Department of Veteran Affairs to a non-VA entity. The patient/veteran must outline which records they wish to release to the third party (typically a private doctor or hospital) and sign the form to authorize the access.

VA Form 10-5345

VA Form 10-5345 is a medical records release form used to request the release of a veteran’s health information held by the Department of Veteran Affairs to a non-VA entity. The patient/veteran must outline which records they wish to release to the third party (typically a private doctor or hospital) and sign the form to authorize the access.

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Last updated April 23rd, 2024

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VA Form 10-5345 is a medical records release form used to request the release of a veteran’s health information held by the Department of Veteran Affairs to a non-VA entity. The patient/veteran must outline which records they wish to release to the third party (typically a private doctor or hospital) and sign the form to authorize the access.

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Multiple Facilities

If a patient received treatments from multiple VA facilities, a separate release form must be completed and sent to each facility in order to access the records held there.

How to Fill Out VA Form 10-5345 (6 Steps)

1. Facility, Patient, and Requestor

The following information must be entered into the first five fields of the form:

  • Name and address of the VAMC (Veterans Affairs Medical Center)
  • Patient’s (veteran) full name
  • Patient’s DOB
  • Patient’s mailing address
  • Name and address of the entity requesting the records (requestor)

2. Release

The reason for requesting the medical records must be indicated by selecting the applicable checkboxes. Treatment, benefits, legal, employment, other, or any combination of these can be selected.

The type of records that will be released can be indicated by selecting any of the checkboxes under “Information Requested.”

3. Sensitive Information

The patient can choose whether they want sensitive diagnoses (drug abuse, alcoholism, etc.) to be released by checking the applicable boxes at the top of page 2 of the form.

4. Expiration

Under “Expiration,” the veteran can indicate at what point the authorization for disclosure will be terminated. Expiration can be after one use, upon a certain date, or upon specific conditions.

5. Authorization

To authorize the release, the patient must sign the document and enter the date. If a representative is signing on their behalf, that individual must sign and date the form and include their name and relationship to the veteran. This form requires the patient or legal representative to sign by hand, i.e., a wet signature.

6. VA Office

The last section of the form can only be completed by a Veterans Affairs member of staff to detail which records were released, when, and by whom.

VA Form 10-5345 (Preview)