VA Form 10 5345a

Information you will need

• What’s the name of the facility?
• What’s the patient's name?
• What’s the patient’s date of birth?
• What’s the patient’s address?
• Is a health summary being requested?
• Is an inpatient discharge summary being requested?
• What’s the time period of the inpatient discharge summary?
• 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?
• What are the specific lab results?
• Are general lab results being requested?
• Which lab results are being requested?
• Are radiology reports being requested?
• What type of radiology reports are being requested?
• Is a list of medications being requested?

…and 12 more fields in the PDF.