Information Collection

Request for and Authorization to Release Medical Records or Health Information, Individual's Request for a Copy of Their Own Health Information

IC 28503 under ICR 200708-2900-014 · OMB 2900-0260.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0260 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-5345 Request for and Authorization to Release Medical Records or Health Information, Individual's Request for a Copy of Their Own Health Information	Form
10-5345 REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL RECORDS 10-5345-fill.pdf www.va.gov/vaforms	Form
10-5345a INDIVIDUALS' REQUEST FOR A COPY OF THEIR OWN HEALTH INFO 10-5345a-fill.pdf www.va.gov/vaforms	Form

IC Title:

Request for and Authorization to Release Medical Records or Health Information, Individual's Request for a Copy of Their Own Health Information

Agency IC Tracking Number:

2900-0260

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 38 CFR 1.577 45 CFR 160 45 CFR 164

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-5345	REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL RECORDS OR HEALTH INFORMATION	10-5345-fill.pdf	http://www.va.gov/vaforms	Yes	No	Fillable Printable
Form	10-5345a	INDIVIDUALS' REQUEST FOR A COPY OF THEIR OWN HEALTH INFORMATION	10-5345a-fill.pdf	http://www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,780,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,780,000	780,000	1,000,000
Annual IC Time Burden (Hours)	59,333	26,000	33,333
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.