Free VA Form 10-5345a-MHV - Individual's Rqst for Med Record from MyHealtheVet - fillable - Federal

OMB Number: 2900-0260 Estimated Burden: 2 minutes

PRIVACY ACT AND PAPERWORK REDUCTION ACT INFORMATION

The information on this form is requested under Title 38, U.S.C. 501. Your disclosure of the information requested on this form is voluntary. However, if the information including Social Security Number (SSN) (the SSN will be used to locate records for release) is not furnished completely and accurately, VA will be unable to comply with the request. Failure to furnish the information will not have any affect on any other benefits to which you may be entitled.

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PHONE NO.

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Act. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 2 minutes. This includes the time it will take to read the instructions, gather the necessary facts and fill out the form. The purpose of this form is to provide an individual the means to make a written request for a copy of their information maintained by the Department of Veterans Affairs (VA) in accordance with 38 CFR 1.577.

VETERAN'S LAST NAME- FIRST NAME- MIDDLE INTIAL

SOCIAL SECURITY NO.

Check applicable box(es) and state the extent or nature of information to be copied/printed, giving the dates or approximate dates covered by each

DESCRIPTION OF INFORMATION REQUESTED

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FACILITY WHERE TREATED:

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DATES OF TREATMENT:

X COPY OF HOSPITAL SUMMARY

X COPY OF OUTPATIENT TREATMENT NOTE(S)

COPY OF HEALTH INFORMATION IS TO BE DELIVERED TO THE INDIVIDUAL X IN-PERSON

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PATIENT SIGNATURE

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I request access to all available electronic health information via My HealtheVet (MHV) account. All prerequisites for In-Person Authentication have been satisfied, including MHV training.

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BY MAIL, TO ADDRESS BELOW (include City, State & ZIP)

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I request all available electronic personal health records through My HealtheVet.

NOTE: If signed by someone other than the patient, indicate the authority (e.g., guardianship or power of attorney) under which request is made.

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VA FORM DEC 2006

10-5345a-MHV

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DATE OF BIRTH X
OTHER (Specify)

INDIVIDUALS' REQUEST FOR A COPY OF THEIR OWN HEALTH INFORMATION

DATE (mm/dd/yyyy)

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My HealtheVet is an online environment where veterans, family, and clinicians may come together to optimize a veteran's health. Veterans are able to access a single source of trusted health information, one stop shopping for VA benefits, a health calendar, self-enter health insurance information, medical events, labs, medications, OTCs and supplements, allergies and immunizations, Military Health History, and nine health trackers (e.g., blood pressure, blood sugar, weight, temperature, cholesterol, pain level). You are able to refill prescriptions online and track information in food and activity journals and personal and family health histories as part of the Personal Health Record (PHR). My HealtheVet offers the first condition centers and healthy living centers and releases copies of key portions of health information contained in VA's electronic health record. My HealtheVet is a Personal Health Record owned and controlled by you. To Upgrade a My HealtheVet Account

As part of the My HealtheVet security measures, you will be asked to verify your identify in person at a VA hospital or Community Based Outpatient Clinic. The release of information staff will ask you to show a valid Veterans Identification Card or form of identification with a picture, review and sign a request to upgrade your My HealtheVet account, and view an orientation video.

My Privacy Rights

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Veterans who are enrolled for VA health care benefits are afforded various privacy rights under Federal law and regulations including the right to a notice of privacy practices. The VA Notice of Privacy Practices provides enrolled veterans with information on how VHA may use and disclose your personal health information. The Notice also advises enrolled veterans of their rights to know when and to whom their health information may have been disclosed; request access to or receive a copy of their health information on file with VA; request an amendment to correct inaccurate information on file; and file a privacy complaint. A copy of the VA Notice of Privacy Practices, IB 10-163, may be obtained through the Internet at http://www1.va.gov/Health_Benefits or through the mail by writing the VHA Privacy Office (19F2),810 Vermont Avenue NW,Washington, DC20420.
VA FORM DEC 2006

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Don't share your user ID and password with anyone. Writing them down is a good idea, but keep them in a safe place, such as a wallet or purse. You may want to print copies of your Personal Health Record to take with you on trips or visits to providers. Be careful not to leave printed material in any public places and store copies in a safe place, like a locked file cabinet. If you share your Personal Health Record with others, VA has no authority to ensure these people protect your privacy. Be careful of who you give copies of your Personal Health Record. If you print updated copies of your Personal Health Record, be sure to destroy your old copies, preferably with a shredder.

10-5345a-MHV

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You will be able to access your My HealtheVet account by logging in anywhere there's Internet access, including public places like libraries. When you log on to My HealtheVet, remember that people may see your personal information on the screen. Turn the screen away from their view. Don't walk away from the computer with your information showing. And always remember to log off when you have finished.

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Here are a few tips for protecting your privacy:

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All information placed in your My HealtheVet account becomes a part of your Personal Health Record. It is not distributed, shared or viewed by the VA, and all privacy and security information listed in the My HealtheVet website terms and conditions still apply. It is important to remember that you also have a responsibility in keeping your health information safe.

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Privacy and Security

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You will be able to view copies of key portions of your VA health record. This will better enable you to monitor and protect your health. You can also print a summary of your Personal Health Record and share it with your VA and non-VA provider to improve the level of care they provide you. The requested health information will be forwarded to your account after an initial delay to provide time for your healthcare provider to review the information and allow personal communication with you on occasion.

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Accessing Copies of Key Portions of Your VA Health Record

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What is My HealtheVet?

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INDIVIDUALS' REQUEST FOR A COPY OF THEIR OWN HEALTH INFORMATION, CONTINUED