Privacy Act information
The purpose of the form, its basis in 38 CFR 1.577 and Title 38 U.S.C., and a statement that disclosure is voluntary and that not furnishing the information will not affect any other benefits.
10-5345a
Individuals' Request for a Copy of Their Own Health Information
- Agency
- VA
- Revision
- July 2021
- Fillable fields
- 43
- Pages
- 1
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-5345a: Individuals' Request for a Copy of Their Own Health Information
VA Form 10-5345a is the U.S. Department of Veterans Affairs Individuals' Request for a Copy of Their Own Health Information. The form says its purpose is to give an individual the means to make a written request for a copy of their information maintained by VA, in accordance with 38 CFR 1.577. It is addressed to the Department of Veterans Affairs, with a box for the name and location of the VA health care facility.
The form is one page. It asks for the patient's name, date of birth and mailing address, a checklist of the records wanted, such as a health summary for the prior 2 years, progress notes, lab results, radiology reports or a list of active medications, and how the copy is to be delivered. The patient signs in ink. The form says giving the information is voluntary, but VA will be unable to comply with the request if the information needed to locate the records is not furnished completely and accurately.
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 10-5345a
Facility and patient details
The name and location of the VA health care facility, the patient's last, first and middle name, date of birth in mm/dd/yyyy and mailing address with city, state and ZIP Code.
Description of information requested
Boxes for a health summary (prior 2 years), inpatient discharge summary, progress notes by clinic, provider or date range, operative or clinical procedures, lab results by test or date range and radiology reports.
More record types
A list of active medications, vaccination details (dose, lot number, date and location), legal health records for torts and an Other box to describe anything else.
Format and delivery
Paper, CD-ROM or other, in-person pick-up with a contact phone number, or mail to the same address as above or a new address.
Signature and date
The patient signature, which the form says to sign in ink, the date and a note on signing for someone else.
How to fill out VA Form 10-5345a
- 1
Name the VA facility
Enter the name and location of the VA health care facility in the TO box.
- 2
Enter the patient's details
Give the name, date of birth and mailing address. The form says VA will be unable to comply if the information needed to locate records is not furnished completely and accurately.
- 3
Check the records wanted
The form says to check the applicable boxes and state the extent or nature of the information, such as clinic or provider names, test names and date ranges.
- 4
Choose format and delivery
Pick paper, CD-ROM or other, then in-person pick-up with a contact phone number, or mail to the same address or a new one.
- 5
Sign in ink and date it
Sign and date the form. If someone other than the individual signs, the note asks for the authority, such as guardianship or power of attorney.
These steps follow the form's own labels.
Why fill Form 10-5345a on indox
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Filing and edition details
Where it goes
The form is addressed to the Department of Veterans Affairs at the VA health care facility named in the TO box. The PDF and VA's form page print no mailing address, fax number or email.
Legal basis
The form cites 38 CFR 1.577 and says the information is requested under Title 38 U.S.C.
Voluntary disclosure
The form says disclosure is voluntary and that failure to furnish the information will not have any effect on any other benefits.
Edition
The PDF is dated JUL 2021, matching the July 2021 revision date on VA's form page. It prints no OMB number.
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Who uses VA Form 10-5345a?
The form describes who makes the request and where it goes.
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Questions about Form 10-5345a
What is VA Form 10-5345a?
It is the Individuals' Request for a Copy of Their Own Health Information. The form says it gives an individual the means to make a written request for a copy of their information maintained by VA, in accordance with 38 CFR 1.577.
Which records can the form ask for?
The checklist includes a health summary (prior 2 years), inpatient discharge summary, progress notes, operative or clinical procedures, lab results, radiology reports, a list of active medications, vaccinations, legal health records for torts and an Other box.
How is the copy delivered?
The form offers paper, CD-ROM or other, and either in-person pick-up with a contact phone number or mail to the same address as above or a new address.
Can someone else sign VA Form 10-5345a?
The form's note says that if it is signed by someone other than the individual, the request indicates the authority under which it is made, for example guardianship or power of attorney.
What if some details are left blank?
The form says disclosure is voluntary, but if the information needed to locate records is not furnished completely and accurately, VA will be unable to comply with the request.
Where is VA Form 10-5345a sent?
It is addressed to the VA health care facility named in the TO box. The PDF and VA's form page print no mailing address.