Va 10-5345a Form 2020-2023

Va 10-5345a Form: What You Should Know

The information is available for viewing but not for copying. For use only by or on behalf of those persons, entities, and government entities for whom it is produced, in accordance with Title 10, U.S.C., 831(e), to obtain a copy of their personal health records that include information of such nature as to authorize access, upon request, to all the records in the system for purposes of examination, diagnosis, and treatment by all the health care providers who have been identified in the records. Individuals who have access to this information may authorize an authorized representative to obtain such information for the individual upon payment of such reasonable charges. If the authorized representative is not the individual's own health care provider, then this information shall be provided to that provider as described in section 1033(a)(3) of title 10, U.S.C. The Department will provide copies of this document electronically to the individual on his or her request on a form approved by the Veterans' Information Program Center on Request for copies of records of personal health care provided by the Department of Veterans Affairs by email at: with the subject “Privacy Act Request for Medical Records.” Individuals who use this form must ensure such request is not addressed to an officer, employee, or agent of the Department of Veterans Affairs. The individual must identify his or her intended use of the records so that appropriate authorization can be granted by the authorized representative identified in the authorization section. The authorized representative may use the form to obtain medical, financial, or health information pertaining to an individual, unless the information is protected from disclosure under Title IV of “Federal law or regulation.” VA, and all recipients of records and records components of the federal government, shall ensure VA provides appropriate and timely authorization for the release or use of personal health information in the privacy Act electronic format. VA requests, in the privacy Act format, that an individual sign the form, including a request that the authorized representative give immediate access to a searchable copy of the records.

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