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VHA 10-0485 (10 year) REQUEST FOR AND AUTHORIZATION TO RELEASE PROTECTED

VHA 10-0485 (10 year) REQUEST FOR AND AUTHORIZATION TO RELEASE PROTECTED-2025

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The document is a request form for the authorization to release protected health information (PHI) to health information exchanges, specifically for treatment purposes. It outlines the legal framework under which the information can be disclosed, including compliance with HIPAA and the Privacy Act. The patient must provide personal details, including their Social Security Number, to facilitate record retrieval. The authorization remains valid for ten years and can be revoked in writing. It emphasizes that providing this information is voluntary but necessary for processing requests related to medical needs.

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What is the VA authorization for release of records?

Use VA Form 10-5345 to authorize us to share your health information with a non-VA (or third-party) individual or organization.

What is the purpose of VA Form 10 5345?

A consent to release medical information form will typically be requested when someone wants a copy of their own medical records or would like to have them sent to a third party. The request is made to the healthcare provider, therapist, or organization that has the patients records.

How to fill out authorization for release of protected health information?

Use VA Form 21-4142 to give us permission to obtain your personal information from a non-VA source like a private doctor or hospital. Examples of personal information may include your medical treatment, hospitalizations, psychotherapy, or outpatient care.

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