REQUEST FOR AND AUTHORIZATION TO RELEASE PROTECTED
HEALTH INFORMATION TO HEALTH INFORMATION EXCHANGES
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.
Patient Full Name
First:
Middle:
Last: (print)
Birth Date
SSN:
Gender:
Female
Male
(mm/dd/yyyy):
Requestor Name:
VA Approved eHealth Exchange and VLER Direct 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, VLER Direct and other Health
Information Exchanges with whom VA has an agreement. 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 ten 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
Date
10-0485
VA FORM
Dec 2016
REQUEST FOR AND AUTHORIZATION TO RELEASE PROTECTED
HEALTH INFORMATION TO HEALTH INFORMATION EXCHANGES
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.
Patient Full Name
First:
Middle:
Last: (print)
Birth Date
SSN:
Gender:
Female
Male
(mm/dd/yyyy):
Requestor Name:
VA Approved eHealth Exchange and VLER Direct 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, VLER Direct and other Health
Information Exchanges with whom VA has an agreement. 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 ten 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
Date
10-0485
VA FORM
Dec 2016