Privacy Act statement
The form says disclosure is voluntary, and that VHA may not condition treatment, payment, enrollment in the VA Health Care Program, or eligibility for benefits on signing, except for research-related treatment.
10-5345
Request for and Authorization to Release Health Information
- Agency
- VA
- Revision
- May 2026
- Fillable fields
- 61
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-5345: Request for and Authorization to Release Health Information
VA Form 10-5345 is the U.S. Department of Veterans Affairs Request for and Authorization to Release Health Information. VA's form page says to use it to authorize VA to share your health information with a non-VA (or third-party) individual or organization. The form names the VA health care facility, the patient, the person or organization receiving the information, the purpose and the records to be released.
The form is two pages. Page 1 holds the Privacy Act statement and the request, page 2 the sensitive diagnoses choices, the authorization, the expiration choice, the signatures and a For VA Use Only block. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 10-5345
Facility, patient and recipient
The name and location of the VA health care facility, the patient's name, date of birth and mailing address, and the name and address of the recipient.
Purpose and information requested
Checkboxes for the purpose, then the records: health summary (prior 2 years), patient medical records, inpatient discharge summary, progress notes, procedures, lab results, radiology reports, active medications, vaccination, administrative records and other.
Sensitive diagnoses
Boxes for drug abuse, alcoholism or alcohol abuse, sickle cell anemia and HIV, for a release for any purpose other than treatment, and a box to keep them from being released for treatment under this authorization.
Authorization and expiration
A certification that the request is made freely and voluntarily, the revocation terms and a choice of when the authorization expires: after a one-time disclosure, on a date or under stated conditions.
Signatures and VA use
The patient signature and date, the legal representative signature if applicable, and the For VA Use Only block.
How to fill in VA Form 10-5345
- 1
Name the facility and the patient
Enter the name and location of the VA health care facility, then the patient's name, date of birth and mailing address. Page 2 repeats the name and date of birth.
- 2
Name the recipient and purpose
Enter who receives the information and check the purpose. For Other, the form asks you to specify it.
- 3
Check the records to release
Check the applicable boxes and state the extent or nature of the information, such as dates, clinics, providers or test names.
- 4
Review the sensitive diagnoses
The form says to review and, if appropriate, complete this part when the release is for any purpose other than treatment.
- 5
Choose when it expires
Select one expiration choice. For a date, the form asks for a future date other than the date signed by the patient.
- 6
Sign in ink and date it
The patient signs and dates the form in ink. A legal representative signs on the separate line if applicable.
Why fill Form 10-5345 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Filing, revoking and edition details
Where it goes
The form is addressed to the Department of Veterans Affairs at the VA health care facility named on it. The form and VA's form page print no mailing address, fax number or email.
Your copy
The authorization says the patient will receive a copy of this form after signing it.
Revoking it
The form says the authorization may be revoked in writing at any time, except to the extent action has already been taken. A written revocation is effective upon receipt by the Release of Information Unit at the facility housing the records.
Redisclosure
The form says any disclosure carries the potential for unauthorized redisclosure, and the information may not be protected by federal confidentiality rules.
Edition
The current edition is dated MAY 2026, which matches the revision date on VA's form page.
Related forms
10-5345a
Individuals' Request for a Copy of Their Own Health Information
43 fields, 1 page
10-259
Revocation of Authorization for Release of Release of Individually-Identifiable Health Information
15 fields, 1 page
10-10163
Request for and Permission to Participate in Sharing Protected Health Information through Health Information Exchanges
9 fields, 1 page
10-10164
Opt-Out of Sharing Protected Health Information Through Health Information Exchanges
9 fields, 1 page
10-252
Authorization to Release Protected Health Information to State/Local Public Health Authorities
7 fields, 1 page
10-0527
Request and Authorization to Release Protected Health Information to the Choice/PC3 Program
9 fields, 1 page
Who uses VA Form 10-5345?
The form and VA's page describe who signs it, who receives the information and who processes it.
Official sources and the blank
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Questions about Form 10-5345
What is VA Form 10-5345 used for?
VA's form page says to use it to authorize VA to share your health information with a non-VA (or third-party) individual or organization.
Does signing affect my VA care?
The Privacy Act statement says VHA may not condition treatment, payment, enrollment in the VA Health Care Program, or eligibility for benefits on signing, except for research-related treatment where an authorization is required.
What are the sensitive diagnoses on the form?
Drug abuse, alcoholism or alcohol abuse, sickle cell anemia and HIV. The form says they may be released for treatment purposes without the boxes checked, unless the box declining release for treatment under this authorization is checked.
How long does the authorization last?
The form offers three choices: after a one-time disclosure if all needs are satisfied, on a future date, or under conditions you specify. Without revocation, it expires on the one chosen.
Can I revoke the authorization?
The form says it may be revoked in writing at any time, except to the extent action has already been taken, and that revocation is effective when the Release of Information Unit at the facility housing the records receives it.
Can someone sign for the patient?
The form has a separate signature line for a legal representative, if applicable, with the representative's printed name and relationship to the patient.