Healthcare VA Records Request Form

HEALTHCARE VA RECORDS REQUEST FORM

Patient Information

Patient Name:

Date of Birth:   Gender:

Identification / Military Service

VA File Number or SSN:

Service Number / Military ID:   Period of Service From:  To:

Recipient / Release To

Release Records To (Name or Organization):

Recipient Phone:   Recipient Fax:

Records Requested

Please indicate the records you authorize to be disclosed (select all that apply):

Complete VA Medical Record (all progress notes, nursing notes, consults)

Mental Health / Behavioral Health Records

Substance Use Disorder Treatment Records (if applicable)

Laboratory and Imaging Reports

C&P Exam Reports and Disability Evaluations

Discharge / Separation Documents (DD214 or equivalent)

Other (specify below)

Records Requested For Period From:  To:

Purpose / Use of Disclosure

Continuation of care

Disability claim / appeal

Personal use

Legal / Third-party review

Insurance or benefits processing

Sensitive Information — Authorization Required

Certain categories of records require explicit authorization. Check the specific categories you authorize to be disclosed:

Mental health psychotherapy notes and psychotherapy treatment records

Substance use disorder treatment records covered by federal confidentiality rules

HIV/AIDS-related records

Genetic testing and genetic information

Reproductive health records (including pregnancy-related)

By checking any of the above categories I expressly authorize the release of those sensitive records for the purpose(s) indicated.

Delivery and Fees

Preferred Delivery Method:

Secure email to recipient address provided

Postal mail to recipient address

Fax to recipient fax number

Fees: I understand that reasonable fees for copying and postage may be charged in accordance with applicable law and policy. If fees apply, they will be communicated prior to processing.

Expiration and Revocation

This authorization will expire on:

I may revoke this authorization at any time by submitting a signed written notice to the releasing VA facility, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures already made while this authorization was in effect.

Acknowledgments and Certification

By signing below, I certify that I am the patient or an authorized representative of the patient. I authorize the Department of Veterans Affairs to disclose the protected health information specified above to the recipient named on this form. I understand that once my health information is disclosed, the recipient may re-disclose it and it may no longer be protected by federal privacy regulations.

I understand that treatment, payment, enrollment, or eligibility for benefits will not be conditioned on my signing this authorization, except when the provision of treatment is solely for the purpose of creating health information to be disclosed to a third party.

Patient Certification

I certify under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge. I authorize release of the records as indicated and understand the conditions and limitations of this authorization.

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