*roircd* place patient label to cover or complete below: protected health information (phi) release authorization mru00695 (06/06/16)patient name: age:dob:sex:account #: med rec #:page 1 of 1patients name:date of birth:ss # (optional):street...
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Redisclosure of my medical records by those receiving the above authorized information use existing stock of va form 10-5345, dated may
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10-5345a. va form. note: if signed by someone other than the patient, indicate the authority (e.g., the time it will take to read the instructions, gather the necessary facts and fill out the
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