Sign date below and return to the address at the top of the form. SIGNATURE type if electronic VA FORM 10-7959c FEB 2017 DATE CHAMPVA OTHER HEALTH INSURANCE OHI CERTIFICATION NOTES DEFINITIONS AND INSTRUCTIONS INSTRUCTIONS Failure to complete all applicable sections on the front can result in a delay or denial of benefits. OMB Number 2900-0219 Estimated burden 10 minutes Department of Veterans Affairs CHAMPVA Other Health Insurance OHI Certification VA Health Administration Center PO BOX...
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Hello welcome to legal help for veterans tutorial videos today we're going to be walking you through the request for an authorization to release medical records or health information form also referred to as be a form 10-5 three four five this form will be one of the forms sent to each client in our initial representation packet the purpose of this form is to authorize the release of your complete treatment records to this office from each respective VA medical center where you treat although most of this form is very self-explanatory there are several common completion areas we repeatedly see veterans make during the completion of this form the first and most common issue comes right away in box number one please note that this form is only used to obtain medical records from VA and medical centers while your private treatment records can be equally important there is an alternate VA form that will authorize access to these records if you do have private medical records the correct form to use is VA form - one - for one for two however the completion of that form will be discussed in further detail in an alternate forthcoming video again this VA form 10 - 5 3 4 5 allows the release of your be AMC records directly to this office the second common issue with this form is found in the information requested box a box is fine right around mid page in order for the VA to release medical records to us they require that you list approximate dates in which you sought treatment at that facility don't worry if you're unable to pinpoint the exact dates or date range of treatment just make sure to provide the dates as best as you can for example if you think you sought treatment at the Bay Pines VA MC at some point in 2007 we would recommend indicating your dates of treatment as January 2007 through December 2007 or even January 2006 through December 2008 just to be safe if you seek ongoing treatment at a particular location you may simply indicate ongoing or continuing in this box as the end date of treatment finally this form may only be used for one specific VA medical center once the completed form is received back from you legal help from veterans will send this form directly to the VA Medical Center you identified pay for if you do seek treatment at multiple VA Medical Center's you must fill out five three four five form for each location for example if you live in Michigan during the summer months and Arizona in the winter months and seek be a treatment in both locations you would need to fill out a separate form for each treating VA MC in Michigan and in Arizona please note that only one VA form five three four five will be sent to you in your initial representation packet should you seek treatment at more than one VA MC we would advise you to make a phone copy for each additional location or leave box one blank and simply include a list of your treating VA MCS on a separate piece of paper we can then complete the legwork here on your behalf and...