Information Collection

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

IC 28503 under ICR 201407-2900-009 · OMB 2900-0260.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-5345a Request for and Authorization to Release Medical Records or Health Information, etc	Form
10-5345a Individuals' Request for a Copy of Their Own Health Info vha-10-5345a-fill.pdf www.va.gov/vaforms/medical/pdf/vha-10-5345a-fill.pdf	Form
VA Form 10-5345a-M Individuals' Request for a Copy of Their Own Health Info 10-5345a-MHV V2.pdf www.va.gov/vaforms/medical/pdf/vha-10-5345a-MHV-fill.pdf	Form
VA Form 10-0485 Request for and Authorization to Release Protected Healt 10-0485 8-27-2014.pdf eBenefits Web Portal also iMedConsent	Form
VA Form 10-5345 Request for and Authorization to Release Medical Records vha-10-5345-fill.pdf eBenefits Web Portal also iMedConsent	Form
VA Form 10-0525a Restriction of the Release of Individually-Identifiable 10-0525a 12-2011.pdf eBenefits Web Portal also iMedConsent	Form and Instruction

IC Title:

Agency IC Tracking Number:

2900-0260

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 38 CFR 1.577 45 CFR 164 45 CFR 160

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-5345a	Individuals' Request for a Copy of Their Own Health Information	vha-10-5345a-fill.pdf	http://www.va.gov/vaforms/medical/pdf/vha-10-5345a-fill.pdf	Yes	No	Fillable Printable
Form	VA Form 10-5345a-MHV	Individuals' Request for a Copy of Their Own Health Information - My HealtheVet (MHV)	10-5345a-MHV V2.pdf	http://www.va.gov/vaforms/medical/pdf/vha-10-5345a-MHV-fill.pdf	Yes	No	Fillable Printable
Form	VA Form 10-0485	Request for and Authorization to Release Protected Health Information to Nationwide Health Information Network	10-0485 8-27-2014.pdf	eBenefits Web Portal also iMedConsent	Yes	Yes	Fillable Fileable
Form	VA Form 10-5345	Request for and Authorization to Release Medical Records or Helath Information	vha-10-5345-fill.pdf	eBenefits Web Portal also iMedConsent	Yes	Yes	Fillable Fileable
Form and Instruction	VA Form 10-0525a	Restriction of the Release of Individually-Identifiable Health Information through Nationwide Health Information Network (NwHIN)	10-0525a 12-2011.pdf	eBenefits Web Portal also iMedConsent	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,311,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 28 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,311,000	1,311,000
Annual IC Time Burden (Hours)	60,550	60,550
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.