10 5345 r 663-2026

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The document is a request form from the Department of Veterans Affairs for the release of medical records protected under 38 U.S.C. 7332. It outlines the process for veterans to authorize the sharing of their medical information, including details about specific conditions such as drug abuse and alcoholism. The form requires patient identification, specifies the information to be disclosed, and states the purposes for which the information will be used, such as legal assistance and coordination of care.

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Click ‘Get Form’ to open the 10 5345 r 663 in the editor.
Begin by entering the patient's name and social security number in the designated fields if the patient data card imprint is not used.
In the 'To' section, specify the recipient's details, including the organization or individual authorized to receive the information.
Check all applicable boxes under 'Veteran's Request' to indicate which conditions are relevant for disclosure, such as drug abuse or alcoholism.
In 'Information Requested', select the types of documents you wish to obtain, like hospital summaries or outpatient treatment notes, and provide any necessary dates.
Clearly state the purpose for which this information will be used by checking all relevant options provided.
Sign and date at the bottom of the form to certify that your request is made voluntarily and accurately.

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