Request for and Authorization to Release Medical Records or Health Information, Individual's Request for a Copy of Their Own Health Information-MHV (My HealtheVet)
ICR 200907-2900-006 · OMB 2900-0260 · Historical Active
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 2900-0260 can be found here:
Request for and Authorization to Release Medical Records or Health Information, Individual's Request for a Copy of Their Own Health Information-MHV (My HealtheVet)
These forms are used to obtain written patient consent for release of medical records to individuals and third parties when the information is considered "protected", the information is covered by confidentiality, privacy or HIPAA statutes, or the individual requests copies of their own records.
US Code:
38 USC 5701
Name of Law: Confidential nature of claims
US Code:
38 USC 7332
Name of Law: Confidentiality of certain medical records
VA erroneously included burden hours for consent forms that only required respondents' signature and over estimated the burden hours for VA Forms 10-5345 and 10-5345a which cost a decrease in burden. The increase in burden is due to the inclusion of VA Form 10-5345a-MHV (My HealtheVet).
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
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 - My HealtheVet (MHV)
2900-0260 justification.doc
Request for and Authorization to Release Medical Records or Health Information; Individual's Request for a Copy of Their Own Health Information - My HealtheVet (MHV)