VA Form 10 5345

Information you will need

• What’s the patient's name?
• What’s the name of the facility?
• What’s the patient’s address?
• Who’s the requesting party?
• Are the records being requested for treatment?
• Are the records being requested for benefits?
• Are the records being requested for legal reasons?
• Are the records being requested for employment?
• Are the records being requested for other reasons?
• What’s the specific purpose of the request?
• Is a health summary being requested?
• Are medical records being requested?
• Is an inpatient discharge summary being requested?
• Are progress notes being requested?
• Are progress notes being requested from specific clinics?
• What are the specific clinics?
• Are progress notes being requested from specific providers?
• What are the specific providers?
• Are general progress notes being requested?
• Which progress notes are being requested?
• Is a list of procedures being requested?
• What are the procedures?
• Are lab results being requested?
• Are specific lab results being requested?

…and 26 more fields in the PDF.

Completed by the provider.