10-5345a INDIVIDUALS' REQUEST FOR A COPY OF THEIR OWN HEALTH INFO

OMB Number: 2900-0260
Estimated Burden: 2 minutes

INDIVIDUALS' REQUEST FOR A COPY OF THEIR OWN
HEALTH INFORMATION
PRIVACY ACT AND PAPERWORK REDUCTION ACT INFORMATION
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements
of section 3507 of the Act. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a
valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 2 minutes. This includes
the time it will take to read the instructions, gather the necessary facts and fill out the form. The purpose of this form is to provide an individual
the means to make a written request for a copy of their information maintained by the Department of Veterans Affairs (VA)in accordance with 38
CFR 1.577.
The information on this form is requested under Title 38, U.S.C. 501. Your disclosure of the information requested on this form is voluntary.
However, if the information including Social Security Number (SSN) (the SSN will be used to locate records for release) is not furnished
completely and accurately, VA will be unable to comply with the request. Failure to furnish the information will not have any affect on any other
benefits to which you may be entitled.
SOCIAL SECURITY NO.

VETERAN'S LAST NAME- FIRST NAME- MIDDLE INTIAL

DATE OF BIRTH

DESCRIPTION OF INFORMATION REQUESTED

Check applicable box(es) and state the extent or nature of information to be copied/printed, giving the dates or approximate dates covered by each
FACILITY WHERE TREATED:

COPY OF HOSPITAL SUMMARY

DATES OF TREATMENT:

COPY OF OUTPATIENT TREATMENT NOTE(S)

OTHER (Specify)

COPY OF HEALTH INFORMATION IS TO BE DELIVERED TO THE INDIVIDUAL
IN-PERSON

BY MAIL, TO ADDRESS BELOW (include City, State & ZIP)

PATIENT SIGNATURE

PHONE NO.

DATE (mm/dd/yyyy)

NOTE: If signed by someone other than the patient, indicate the authority (e.g., guardianship or power of attorney) under which request is made.
FOR VA USE ONLY
IMPRINT PATIENT DATA CARD (or enter Name, Address, Social
Security Number)

TYPE AND EXTENT OF MATERIAL RELEASED

DATE RELEASED

VA FORM
MAY 2005

10-5345a

RELEASED BY