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REQUEST FOR AND AUTHORIZATION TO RELEASE HEALTH …
WEBThe information requested on this form is solicited under Title 38 U.S.C. The form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164; 5 U.S.C. 552a; and 38 U.S.C. 5701 and 7332 that you specify. Your disclosure of the information requested on this form is
Actived: 8 days ago
URL: https://www.unisourcediscovery.com/wp-content/uploads/2021/02/VHA-Form-10-5345-Fill-revision-1.pdf
Important: Please download and save a copy of this form …
WEBAdditional Requirements: Photo ID: For your protection, please include a legible copy of a photo ID or other government-issued ID along with the authorization form for identity verification purposes. If you will be picking up your records in-person, you will be asked to provide your Photo ID at that time.
Consent for Release of Information
WEBIf you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social Security office. I am the individual, to whom the requested information or record applies, or the parent or legal guardian of a minor, or the
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PRIVACY ACT AND PAPER WORK REDUCTION ACT …
WEBThe information requested on this form is solicited under Title 38 U.S.C. The form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164; 5 U.S.C. 552a; and 38 U.S.C. 5701 and 7332 that you specify. Your disclosure of the information requested on this form is
Unisource Discovery HIPAA Authorization
WEBI further authorize Unisource Discovery, Inc., a private company and/ Client to obtain a copy of such records as are needed for the above stated purpose on behalf of Client and/or its agents. I have read the above and also have been advised of my right to receive a true copy of this authorization. Further, I understand the contents of this
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