Form 10-0400 VSO Access to VHA Electronic Health Records

OMB Approval Number 2900-XXXX
Estimated Burden Avg: 2 minutes

VSO Access to VHA Electronic Health Records
Section 1: To be completed by VSO Representative
1. Last Name

2. First Name

4. Office Phone Number

5. Extension

6. Office E-mail

7. SSN

8. Date of Birth

9. Veteran Service Organization(s)

10. Organization Code(s)

11. I am located at a (check one):

3. Middle Initial

12. If located at a VAMC or VARO please provide:
Station Name

VAMC
VARO

Station Number

VSO Mailing Address:

By signing below, I affirm that I will notify HDI of any change in my position or duties as related to my EHR access
13. Signature of Individual Requesting Access

14. Date

Section 2: TO BE COMPLETED BY THE LOCAL ISO/Alternate
I affirm with my signature below that I have verified that the applicant has provided proof of the following:
 The Requestor is an accredited representative of the Veteran Service Organization.
 The Requestor has completed the VA Cyber Security Awareness Course within the past 365 days.
 The Requestor has completed VHA Privacy Policy Training within the past 365 days.
 The Requestor has completed the VBA VSO Training.
 Copies of the requestor's training certificates of completion for both courses of instruction are on file at this facility.
If I learn the VSO representative no longer complies with requirements for access to VHA EHRs, I will immediately notify HDI
15. ISO Name

16. ISO E-mail Address

17. VHA Privacy Policy Training Date of VSO Rep.

18. VA CyberSecurity Training Date of VSO Rep.

19. ISO Signature

20. Date

Section 3: Health Data & Informatics
Authorizing HDI Official (check one):

Initials:

Director, VHA Office of Health Data & Informatics (19F)
VHA Privacy Officer

VA FORM
JAN 2008

10-0400

Date

Access Restriction:
Restricted Patient List

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VSO Electronic Health Record Access Agreement
The following security policies and rules of behavior apply to accredited representatives of Veterans Service Organizations
(VSOs) who have requested access to Veterans Health Administration (VHA) electronic health records (EHRs) through
Compensation and Pension Record Interchange (CAPRI). Taking into consideration that written guidance cannot cover every
contingency, personnel are asked to go beyond the stated rules, using their best judgment and highest ethical standards to guide
their actions. Personnel must understand that these rules are based on Federal laws and regulations, as well as Department of
Veterans Affairs (VA) and VHA Directives. As such, there are consequences for noncompliance with these rules. Depending on
the severity of the violation, and as authorized in Title 38 Code of Federal Regulations (CFR) §14.633, consequences can include:
suspension of access privileges, termination of accreditation, and criminal and civil penalties.
As an authorized CAPRI user, the VSO agrees to the following:
1. I agree and understand that I will have access to individually-identifiable health information. I understand that I will be given
sufficient access to perform my assigned duties for this project. I will use this access only for its intended purpose. I
understand that I am personally accountable for my actions.
2. I agree to notify the Office of Health Data and Informatics (HDI) upon expiration of any Power of Attorney (POA) for
which I have been granted access to a veteran's individually-identifiable health information through CAPRI.
3. I agree to use CAPRI to view a veteran's EHR only when my respective service organization, or I as an individual
representative of the VSO, holds a valid POA for that veteran. VSO access is restricted to only those veterans' records for
which a VSO has a valid VA POA. I agree that prior to using CAPRI to view a veterans' EHR, I will query the VBA BDN
SHARE to verify that my respective VSO holds a valid POA. If it is determined that it is not a valid POA, I will not use
CAPRI to access that particular veteran's EHR. I will also communicate to HDI ([email protected]) that the POA is no longer
valid.
4. I understand that all conditions and obligations imposed upon me by these rules apply during the entire time I am granted
access to this system, unless and until VHA releases me from these requirements in writing. I understand that a violation of
this notice constitutes disregard of Federal law, as well as local and/or VHA policy and will result in appropriate disciplinary
action as authorized in 38 CFR §14.633, including potential termination of accreditation and access privileges, as well as
criminal and civil penalties.
The VSO representative plays a vital role in maintaining the privacy and confidentiality of a veteran's EHRs. The VA depends on
the full VSO cooperation and communication to prevent or minimize the risk of unauthorized disclosure of a veteran's health
information.
I affirm with my signature in above form that the statements are true and correct to the best of my knowledge and belief.
(PENALTY: The law provides severe penalties, which include fine or imprisonment, or both, for the willful submission of any
statement or evidence of material fact knowing it to be false.)

I affirm with my signature below that I have read and understand the VSO Electronic Health Record
Agreement.

Service Officer Signature:

VA FORM
JAN 2008

10-0400

Date:

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Submit this Completed form and supporting documentation to your local ISO.
General Information for VSO Representatives
•

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•
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Once your packet is approved, you will be granted access to the EHRs of veterans for whom you hold valid POA,
subject to Federal Law and VA Policy.
o You are not required to submit a separate VA Form 10-0400 for each veteran you represent.
o When your access to the EHR of an individual veteran is terminated, you will still be able to access EHRs of
veterans for whom you still hold valid POA.
If you receive notice that your POA for a veteran has been revoked, you are required to notify VHA immediately. If
you find that you still have electronic access to records for which you do not hold a POA, you do not hold legal
authority to access or view those records.
You are required to meet annual training requirements and submit documentation of satisfactory completion to VHA.
If your EHR access is terminated for any reason, you will be required to submit a new 10-0400 form and supporting
documentation.

Submitting a Packet for CAPRI access:
•
•

Fax your packet to the Office of Health Data and Informatics (HDI) at (727) 319-1221. This fax line is secure.
Send an email from your VA account to [email protected] stating that the submission packet to obtain EHR access has
been submitted.

Contacting the VHA Office of Health Data and Informatics
•

If you have any questions about access to VHA EHRs, or if you need assistance preparing or submitting your packet,
please contact HDI at [email protected]

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 Paperwork Reduction Act of 1995. 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
instructions, gather the necessary facts and fill out the form. Although completion of this form is voluntary, VA will be unable to
provide reimbursement for services rendered without a completed form. Failure to complete the form will have no effect on any
other benefits to which you may be entitled. This information is collected under the authority of Title 38 CFR Parts 51 and 52.
Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized
under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., congressional
communications, Federal agencies in regards to health care practices, program review purposes and the seeking of accreditation
and/or certification, officials of labor organizations when relevant and necessary to their duties of representation) as identified in
the VA system of records, “Veterans Health Information Systems and Technology Architecture (VistA) RecordsVA” (79VA19) , published in the Federal Register. Your obligation to respond is voluntary. However, the requested information
is considered relevant and necessary to recognize a service organization as your representative and/or identify disclosable records.
Providing your SSN is also voluntary. However, refusal to provide your SSN will result in VA's inability to provide you access to
VHA electronic health records. The VHA electronic health records system requires SSN in order to establish an user account. The
responses you submit are considered confidential. Information submitted is subject to verification through computer matching
programs with other agencies.

VA FORM
JAN 2008

10-0400

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