OMB.report

Federal forms, ICRs, and supporting documents

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
Document Name
Document Type
Form
Form
Form
Form
Form
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Request for and Authorization to Release Medical Records or Health Information, etc 2900-0260
 
No Modified
 
Voluntary
 
38 CFR 1.577 45 CFR 164 45 CFR 160

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

Health Health Care Services

 

1,311,000 0
   
Individuals or Households
 
   28 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,311,000 0 0 0 0 1,311,000
Annual IC Time Burden (Hours) 60,550 0 0 0 0 60,550
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.