Request for and Authorization to Release Medical Records or Health Information, etc

Forms and Documents

Document Name	Status
Form 10-5345a Request for and Authorization to Release Medical Records or Health Information, etc Form	Modified
2900-0260_justification (v6.1).docx Supporting Statement A	2013-02-28

IC Document Collections

IC ID	Document Title	Status
28503	Request for and Authorization to Release Medical Records or Health Information, etc Form	Modified

ICR Details

OMB Control No: 2900-0260	ICR Reference No: 201206-2900-012
Status: Historical Active	Previous ICR Reference No: 200907-2900-006
Agency/Subagency: VA	Agency Tracking No: 2900-0260
Title: Request for and Authorization to Release Medical Records or Health Information, etc
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/22/2013
	Date Received in OIRA: 10/25/2012
Terms of Clearance: VA is reminded to include the OMB Control Number and required legal statement indicating that an individual may not be required to respond to an information request that does not display a currently valid OMB control number.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2016	36 Months From Approved	03/31/2013
Responses	1,311,000	0	1,300,000
Time Burden (Hours)	60,550	0	65,000
Cost Burden (Dollars)	0	0	0

---

Abstract: 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.

---

Authorizing Statute(s): 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
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 42555	07/19/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 64387	10/19/2012
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Request for and Authorization to Release Medical Records or Health Information, etc	VA Form 10-0525a, 10-5345a, VA Form 10-5345a-MHV, VA Form 10-0485, VA Form 10-5345	Individuals' Request for a Copy of Their Own Health Information ,   Individuals' Request for a Copy of Their Own Health Information - My HealtheVet (MHV) ,   Request for and Authorization to Release Protected Health Information to Nationwide Health Information Network ,   Request for and Authorization to Release Medical Records or Helath Information ,   Restriction of the Release of Individually-Identifiable Health Information through Nationwide Health Information Network (NwHIN)

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,311,000	1,300,000	0	11,000	0	0
Annual Time Burden (Hours)	60,550	65,000	0	550	-5,000	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: VA Forms 10-0525A and 10-0485 are new forms that contribute to the Program Change and increase in burden hours. Also, the time to complete VA Form 10-5345 was reduced from 3 minutes to 2 minutes.

---

Annual Cost to Federal Government: $13,676,313

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 10/25/2012

---