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

OMB Number: 2900-0260
Estimated Burden: 3 minutes
Expiration Date: XX/XX/XXXX

REQUEST FOR AND AUTHORIZATION TO RELEASE PROTECTED
HEALTH INFORMATION TO eHEALTH EXCHANGE
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, eHealth Exchange 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 24VA10P2 "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 eHealth 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.
Paperwork Reduction Act Information: 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 Act. 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 3 minutes. This includes the time it will take to read the instructions, gather the necessary facts and fill out the form. The purpose
of this form is to provide an individual the means to make a written request for a copy of their information maintained by the Department of Veterans
Affairs (VA)in accordance with 38 CFR 1.577.

Patient Full Name
Last: (print)

First:

Middle:

Birth Date
(mm/dd/yyyy):

SSN:

Gender:

Male

Female

Requestor Name:
VA Approved eHealth Exchange Participants and other Health Information Exchanges with whom VA has an agreement.

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 eHealth Exchange. 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
AUG 2014

10-0485

Date