VA Form 10-0485 Request for and Authorization to Release Protected Healt

Request for and Authorization to Release Protected Health Information to
Nationwide Health Information Network

Privacy Act Information: The execution of this form does not authorize the release of information other than that
specifically described below. The information requested on this form is solicited under Title 38, U.S.C. The form
authorizes release of information in accordance with The Health Insurance Portability and Accountability Act,
(HIPAA) 45 CFR Parts 160 and 164, 5 U.S.C. 552a, and 38 U.S.C. 5701 and 7332 that you specify. Your disclosure
of the information requested on this form is voluntary. However if the information containing the Social Security
Number (SSN) (the SSN will be used to locate records for release) is not furnished completely and accurately,
Nationwide Health Information Network will be unable to comply with the request. The Veterans Health
Administration may not condition treatment, payment, enrollment or eligibility on signing the authorization. VA may
disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the
information as outlined in the Privacy Act systems of records notices identified as 24VA19 "Patient Medical Record VA" , and 168VA10P2 “Virtual Lifetime Electronic Record (VLER), and in accordance with the VHA Notice of
Privacy Practices. You do not have to provide the information to VA, but if you do not, the Nationwide Health
Information Network exchange will be unable to process your request and serve your medical needs. Failure to
furnish the information will not have any affect on any other benefits to which you may be entitled. VA may also use
this information on this form to identify Veterans and persons claiming or receiving VA benefits and their records,
and for other purposes authorized or required by law.
Patient Full Name
Last: (print)

First:

Middle:

Birth Date (mm/dd/yyyy):

SSN:

Gender:

Requestor Name:

Male

Female

VA Approved Nationwide Health Information Network Participants

Information Requested:
Pertinent health information from electronic health record.

I request and authorize my VA health care facility to release my protected health information (PHI) for treatment
purposes only to the communities that are participating in the Nationwide Health Information Network. This
information may consist of the diagnosis of Sickle Cell Anemia, the treatment of or referral for Drug Abuse, treatment
of or referral for Alcohol Abuse or the treatment of or testing for infection with Human Immunodeficiency Virus. This
authorization covers the diagnoses that I may have upon signing of the authorization and the diagnoses that I may
acquire in the future including those protected by 38 U.S.C. 7332.
This authorization will remain in effect for the period of five years. I may revoke this authorization, in writing, at any
time except to the extent that action has already been taken to comply with it. Written revocation is effective upon
receipt by the Release of Information Unit at my VA health care facility. Redisclosure of my electronic health records
by those receiving the above authorized information may be accomplished without my further written authorization
and may no longer be protected.
AUTHORIZATION: I certify that this request has been made freely, voluntarily and without coercion and that the
information given above is accurate and complete to the best of my knowledge.

Signature of Patient
VA FORM
MAR 2011

10-0485

Date