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This document is a form for individuals to request a copy of their health information from the Department of Veterans Affairs (VA) under the Privacy Act. It outlines the necessary personal information required for the request, including patient details and specific types of health records desired. The form emphasizes that providing complete and accurate information is essential for processing the request.

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Where do I send my VA form 10 5345A?

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.

What is a VA medical release form 10 5345?

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

Where do I send my VA claim form?

Department of Veterans Affairs. Evidence Intake Center. PO Box 4444. Janesville, WI 53547-4444.

What is VA form 10 5345 used for?

2:45 4:21 You must fill out 5345. Form for each location.MoreYou must fill out 5345. Form for each location.

How do I release medical records to the VA?

Requests for preauthorization can be made to the Health Administration Center by mail: VA Health Administration Center, PO Box 469065, Denver, Colorado 80246-9065 or, if the service is urgent, telephone (833-930-0816), or FAX (303-331-7807).

form 10 5345a

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Where do I send my VA apportionment form?

After completing the form, mail to: Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.

Where do I send VA form 10 5345a?

How to submit a medical records request. Youll need to fill out an Individuals Request for a Copy of Their Own Health Information (VA Form 10-5345a). Submit your completed form to your VA health facilitys medical records office. This office is also called a Release of Information Office.

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