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requested on this form is solicited under Tile 38US.C.The form authorizes release of information in  \u003Cbr>accordance with the Health Insurance Portability and Accountability Act,45CFR Parts 160 and 164;5U.S.C.552a;and 38 U.S.C.5701 and 7332 thatyou specify.  \u003Cbr>Your disclosure of the information requested on this form is voluntary.However,if information needed to locate records for release is not furnished completely and  \u003Cbr>accurately,VA wllbe unable to comply with the request.The Veterans Health Administration may not condition the provision of treatment,payment,enrollment in  \u003Cbr>the VAHealth Care Program,or eligibility for benefits on the signing of an authorization,except for research-related treatment where an authorization for the use or  \u003Cbr>disclosure of individually-identifiable health information for such research is rquied.VA may disclose the information that you puton he form as permitted by  \u003Cbr>law.VA may make a \"routine use\"disclosure of the information as outlined inthe rivacy Act system of records notices identified as 24VA0A7\"Patient Medical  \u003Cbr>Record -VA\",08VA05 \"Employee Medical File System Records(Title 38)-VA\"and inaccordance with the Notice of Privacy Practice.VAmay also use this  \u003Cbr>information to identify Veterans and person claiming or receiving VA benefits and their records,and for other purposes authorized or required by law.   |  |\n| TO:DEPARTMENT OF VETERANS AFFAIRS (Name and Location ofthe VA Health Care Facility)   |  |\n| LAST NAME-FIRST NAME-MIDDLE NAME   | DATE OF BIRTH(MM/DD/YYYY)   |\n| PATIENT'S MAILING ADDRESS(including City,State and Zip Code)   |  |\n| NAME AND ADDRESS OF ORGANIZATION,INDIMDUAL,OR TITLE OF INDVIDUAL TOWHOM INFORMATION IS TO BE RELEASED   |  |\n| PURPOSE(S)OR NEED:Information is to be used by the requestor for:  \u003Cbr>□LEGAL □EMPLOYMENT □OTHER  \u003Cbr>TREATMENT □BENEFITS  \u003Cbr>(Please specify other):   |  |\n| INFORMATION REQUESTED:Check applicable box(es)and state the extent or nature of information to be provided:  \u003Cbr>□HEALTH SUMMARY (Prior 2 Years)  \u003Cbr>□PATIENT MEDICAL RECORDS (Dates):  \u003Cbr>□INPATIENT DISCHARGE SUMMARY (Dates):  \u003Cbr>□PROGRESS NOTES:  \u003Cbr>□SPECIFIC CLINICS (Name &Date Range):  \u003Cbr>□SPECIFIC PROVIDERS (Name &Date Range):  \u003Cbr>□DATE RANGE (Specify Date Range):______             ____  \u003Cbr>□OPERATIVE/CLINICAL PROCEDURES (Name &Date):  \u003Cbr>□LAB RESULTS:  \u003Cbr>□SPECIFIC TESTS (Name &Date):  \u003Cbr>DATE RANGE (Specify Date Range):  \u003Cbr>□RADIOLOGY REPORTS (Name &Date):_____             __  \u003Cbr>□LIST OF ACTIVE MEDICATIONS (Specify Active Medications):  \u003Cbr>□VACCINATION  \u003Cbr>Dose,Lot Number,Date &Location):  \u003Cbr>□ADMINISTRATIVE RECORDS (Specify Administrative Records):  \u003Cbr>□OTHER (Describe):   |  |\n\n\n| LAST NAME-FIRST NAME-MIDDLE NAME   |  |  | DATE OF BIRTH (MMDD/YYYY)   |\n| --- | --- | --- | --- |\n| SENSITVE DIAGNOSES:REVIEW AND,IF APPROPRIATE,COMPLETE WHEN RELEASE IS FORANY PURPOSE OTHER THAN  \u003Cbr>TREATMENT.  \u003Cbr>Irequest and authorize Department of Veterans Affairs to release the information pertaining to the condition(s)below for the non-treatment purpose  \u003Cbr>(s)listed in this authorization.  \u003Cbr>SICKLE CELL ANEMIA  \u003Cbr>□ALCOHOLISM OR ALCOHOL ABUSE  \u003Cbr>□DRUG ABUSE  \u003Cbr>□HUMAN IMMUNODEFICIENCYVIRUS(HIV)  \u003Cbr>lunderstand that information on these sensitive diagnoes maybe released for treatment purposes without me checking the above boxes,and will be  \u003Cbr>reeased even if the boxes are unchecked unless I indicate by checking the box below that I do not want this information released for this specific  \u003Cbr>disclosure.  \u003Cbr>I do not want sensitive diagnoses released for treatment prposes under this specific authorization.Irealiz this does not impact  \u003Cbr>other future requests unrelated t this authorization.   |  |  |  |\n| AUTHORIZATION:Icertify that this request has been made frely,voluntarily and without co","cbCaiadAjsEYgiLm","https://ap.wps.com/l/cbCaiadAjsEYgiLm","pdf",861890,"English","# Authorization to Release Health Information\n## Privacy Act and HIPAA Authorization\n## Patient and Request Details\n## Information Requested and Sensitive Diagnoses\n## Certification, Expiration, and Signatures","[{\"question\":\"What information does this form request to be released by the VA?\",\"answer\":\"It asks the requester to specify the type of information, such as health summaries, medical records, discharge summaries, progress notes, clinic or provider records, lab results, tests, radiology reports, active medications, vaccination details, administrative records, or other descriptions.\"},{\"question\":\"How does the form handle sensitive diagnoses?\",\"answer\":\"A sensitive diagnoses section is provided for conditions beyond treatment purposes, with instructions about reviewing and completing it when release is for non-treatment purposes and for the treatment-related handling when boxes are not checked.\"},{\"question\":\"When does the authorization expire?\",\"answer\":\"The authorization automatically expires unless revoked, based on a selection of either after one-time disclosure (with a specified future date) or under specified condition(s) defined by the signer.\"}]","Request for and Authorization to Release Health Information - VA Form 10-5345 | PDF",1789622399]