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Va Form 10-5345: What You Should Know
For further information, visit Health Care Finance Administration's “Federal Websites” page — or call a local phone VA Form 10-5345 — Seattle.gov 10-5345. VA FORM. JUN 2017. Page 2 of 2. LAST 4 SSN PRIVACY ACT INFORMATION: This form requires the following information to be sent or otherwise provided by you to the Department of Veterans' Affairs: Acknowledgement of receipt of the Notice of Privacy Act Disclosures (Notice) that is attached hereto and located at the bottom of this form. Notice Information Notice Number No. Notice Date 11-16-16 6-10-17 6-10-17 5-3-19 11-30-17 VARIANTS OR OTHER INFORMATION THAT MAY BE RELEASED Use EXISTING STOCK OF VA FORM 10-5345, DATED NOV 2004. OMB Number: 2. Estimated Burden: 1 minute. Privacy Act and Paperwork Reduction Act. See below Health Insurance Portability and Accountability Act of 1996: Information that requires access under the Federal Health Insurance Protocol Access to Health Information. Portability and Accountability Act of 1998 (Pub. L. 104-199), 45 U.S.C. CHAPTER 37B: INFORMATION TO BE RELEASED. Use EXISTING STOCK OF VA FORM 10-5345, DATED NOV 2004. OMB Number: 2. Estimated Burden: 1 minute. Privacy Act and Paperwork Reduction Act. See below. Section 1081.50(b) of the Internal Revenue Code: See below. Access the U.S. Office of Management and Budget's “Federal Websites” (or call a local phone number) or call the Veterans Information Hotline on -1 if you have questions about accessing information for the Veterans' Affairs. Health Information Portability and Accountability Act of 1996: Information that requires access under the Federal Health Insurance Protocol Access to Health Information. Use EXISTING STOCK OF VA FORM 10-5345, DATED NOV 2004.
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