Consent Form

Consent For Project ARCH
Project ARCH (Access Received Closer to Home) is a pilot program offered by the Department of Veterans
Affairs (VA) which was established by Section 403 of Public Law 110-387. The purpose of Project ARCH is to
look at alternative ways to provide the care you need. You will receive treatment options outside the current
VA health care system by participating in the pilot program until August 29, 2014
.
(INSERT DATE PILOT ENDS HERE)

You can still receive care through VA while participating in Project ARCH. VA hopes to make it easier for
Veterans to receive care through this program by providing more health care options closer to home.
VA will refer you to a Project ARCH health care provider to cover your care. Your local VA medical center
will provide more details about what treatments you can get from qualified Project ARCH health care
provider(s).
VA will share your health information with the Project ARCH health care provider(s). This is necessary to keep
your treatment records up to date and ensure there are no gaps in your care. VA may ask you to sign a written
approval to share some of your health information with the Project ARCH health care provider(s) who will take
care of you. You may also receive a patient satisfaction survey that is designed for you to express your
experience and satisfaction with Project ARCH. VA will also provide reports to Congress on how well this
program works.
By signing this document, you acknowledge that you understand the purpose of Project ARCH, the effect on
your privacy, and that you would like to participate in the pilot program.

Veteran Name (Type or Print Legibly)

Signature of Veteran

Date Signed

PRIVACY ACT STATEMENT: Title 38, U.S.C. covers the information this form requests. You must be willing to provide this information. If you do not complete all this
application, or if the information you provide is not accurate, the Department of Veterans Affairs (VA) will not permit you to be a part of Project ARCH. As the law permits,
VA may share the information that you give on the form. VA may make a "routine use" disclosure of the information as outlined in the Privacy Act (24VA19), “Patient Medical
Record-VA”. This is a part of VHA Notice of Privacy Practices. VA will not change your benefits if you choose to not provide the information or sign the form

VA FORM
NOV 2010

10-0504