Who needs a VA Form 10-5345?
VA Form 10-5345 is used by veterans who have been treated at a health care facility of the Department of Veterans Affairs.
What is VA Form 10-5345 for?
VA Form 10-5345 is a document whereby a veteran requests and authorizes Department of Veterans Affairs to release information to a particular individual or organization specified in the Form.
Is VA Form 10-5345 accompanied by other forms?
No other form is required to be submitted with VA Form 10-5345. However, if the veteran authorizes a representative to sign the form on his/her behalf, the respective power of attorney should be attached to the Form.
When is VA Form 10-5345 due?
You should ask the treatment facility when the Form is due; it depends on your personal circumstances.
How do I fill out VA Form 10-5345?
In the first box, you should enter the name and address of the health care facility where you were treated; this information may be entered by the facility.
At the beginning of the Form, you should enter your name and social security number.
In “Veteran’s Request” item, you should check the respective boxes: “drug abuse”, “alcoholism or alcohol abuse”, “testing for or infection with HIV”, or “sickle cell anemia”. This is to confirm that you understand that the information to be released may include information about the above-mentioned conditions.
In item “Information requested”, you should check one or more applicable boxes: “copy of hospital summary”; “copies of outpatient treatment notes” or “other (specify)”. In the field that follows you should specify the nature or extent of the information to be disclosed, giving the respective dates.
Your authorization may expire automatically on a certain date or under certain conditions, without your revocation. You may specify such a date or conditions filling the respective boxes in item “Authorization”.
Finally, you should sign and date the Form.
Your disclosure of the information requested on the Form is voluntary. However, if the information provided, including Social Security Number, is incomplete and inaccurate, Department of Veterans Affairs will be unable to comply with the request.
Where do I send VA Form 10-5345?
You should send the completed Form to the facility specified in the first box of the Form.