Patient full name
Last name (print), first name and middle name.
10-0525
Revocation of Restriction of the Release of Individually-Identifiable Health Information Through eHEALTH Exchange
- Agency
- VA
- Revision
- February 2014
- Fillable fields
- 9
- Pages
- 1
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-0525: Revocation of Restriction Through eHealth Exchange
VA Form 10-0525 is the U.S. Department of Veterans Affairs Revocation of Restriction of the Release of Individually-Identifiable Health Information Through eHealth Exchange. VA's form page lists it under VHA. The form says its purpose is revocation of all restrictions requests on the electronic exchange of individually-identifiable health information between VA and non-VA health care provider organizations participating in the eHealth Exchange.
The form says that by revoking all restrictions requests, the sharing of your electronic health information to non-VA health care provider organizations through the eHealth Exchange is no longer restricted or limited in any way.
The form is one page: the patient's name and the last four digits of the SSN, three statements about the revocation, and signature lines for the patient and for a legal representative if applicable. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 10-0525
Last four digits of SSN
The form asks only for the last four digits of the Social Security number.
Revocation of restriction request
Three statements: the request to revoke all previous restrictions, a certification that the revocation is made freely, voluntarily and without coercion, and an acknowledgment that health information will be shared with all non-VA providers in the exchange.
Patient signature
The signature section says the revocation has been explained to the signer and that all restrictions are revoked, followed by the patient's signature and date.
Legal representative
Signature and date of a legal representative, if applicable, and the representative's printed name.
How to fill out VA Form 10-0525
- 1
Print the patient's name
Enter the last name in print, then the first and middle names.
- 2
Add the last four SSN digits
Enter only the last four digits of the Social Security number.
- 3
Read the three statements
They state that ALL previous restrictions are revoked and that VA electronic health information will then be shared with all non-VA providers through eHealth Exchange.
- 4
Sign and date it
The patient signs and dates the form. A legal representative, if applicable, signs, dates and prints their name.
Why fill Form 10-0525 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Sending it and other notes
Where it goes
The form and VA's form page do not print a mailing address, fax number or office to send it to.
Scope of the revocation
The form revokes ALL restrictions previously submitted. It has no option to revoke only some of them.
Edition
The PDF footer is dated FEB 2014. VA's form page lists a form revision date of May 2014. The PDF text does not print an OMB control number.
Related forms
10-0525a
Restriction of the Release of Individually-Identifiable Health Information Through eHEALTH Exchange
25 fields, 2 pages
10-10163
Request for and Permission to Participate in Sharing Protected Health Information through Health Information Exchanges
9 fields, 1 page
10-10164
Opt-Out of Sharing Protected Health Information Through Health Information Exchanges
9 fields, 1 page
10-0527
Request and Authorization to Release Protected Health Information to the Choice/PC3 Program
9 fields, 1 page
Who uses VA Form 10-0525?
The form names the patient and, if applicable, a legal representative.
Official sources and the blank
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Questions about Form 10-0525
What does VA Form 10-0525 do?
The form says it revokes all restrictions requests on the electronic exchange of individually-identifiable health information between VA and non-VA health care provider organizations participating in the eHealth Exchange.
Can I revoke only some of my restrictions?
The form has no option for that. Statement 1 asks VHA to revoke ALL restrictions previously submitted on the release of health information for treatment purposes through the eHealth Exchange.
What happens after the revocation?
Statement 3 says revocation of the previous restrictions will result in VA electronic individually-identifiable health information being shared with all non-VA health care provider organization(s) through eHealth Exchange.
Who signs VA Form 10-0525?
The patient signs and dates it. The form also has a signature, date and printed name line for a legal representative, if applicable.
Which form sets a restriction in the first place?
VA Form 10-0525a, Restriction of the Release of Individually-Identifiable Health Information Through eHEALTH Exchange. Its text says its purpose is to capture a request to restrict sharing through the eHealth Exchange.