10-0525a
Restriction of the Release of Individually-Identifiable Health Information Through eHEALTH Exchange
VA Form 10-0525a is the U.S. Department of Veterans Affairs Restriction of the Release of Individually-Identifiable Health Information Through eHealth Exchange. The form says its purpose is to restrict the electronic exchange of individually-identifiable health information between VA and non-VA health care provider organizations that participate in the eHealth Exchange.
The patient names which participating non-VA organizations should NOT receive their electronic health information. The form says a restriction applies only to sharing through the eHealth Exchange, and that it stays in effect until revoked or replaced.
The form is two pages: a Privacy Act notice, the patient's name and last four digits of the Social Security number, the restriction rules, a list of organizations to choose from and the signature section. You can fill out the PDF free in your browser on this page and download the result without an account.
The opening notice says giving the information is voluntary, but that without a complete and accurate Social Security number, used to locate records, VA will be unable to comply with the restriction request.
The patient's full name, with last, first and middle name printed, and the last four digits of the Social Security number.
Three numbered points: the right to ask VA to limit sharing, how a request works when no authorization is on file, and that a restriction covers only sharing through the eHealth Exchange.
A list of participating organizations, including Kaiser Permanente, Med Virginia, Multicare, Utah Health Information Network and Western New York HealtheLink, to mark the ones that should not receive the information.
Four statements the patient agrees to, then lines for the patient's signature and date, a legal representative's signature and date, and the representative's printed name.
Print the patient's last, first and middle name and the last four digits of the Social Security number.
The form says to mark all of your choices at this time, covering every non-VA health care organization you wish to restrict.
The statements say the request is made freely and voluntarily, stays in effect until revoked or replaced, and supersedes and replaces all previous requests.
The patient signs and dates the form. A legal representative signing instead also prints their name and attaches the authority to sign.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The form and VA's form page do not print a mailing address, fax number or online way to submit it.
The form says the restriction remains in effect until revoked or replaced, and that it may be revoked in writing or electronically through the eBenefits Portal at any time, except where action has already been taken.
The form says a new request supersedes and replaces all previous requests and represents all of the patient's restriction choices.
The edition is dated JUN 2013. The form carries OMB Number 2900-0260.
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The form describes who signs it and how VA applies it.
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The form says its purpose is to restrict the electronic exchange of individually-identifiable health information between VA and non-VA health care provider organizations participating in the eHealth Exchange.
No. The form says any restriction request applies only to the sharing of electronic health information through the eHealth Exchange.
Yes. The form says a request may be filed without an authorization on file, but it stays in inactive status until an authorization is filed.
The form says that once the request is submitted, VA will not share the information with the selected organizations through the eHealth Exchange even if you later sign an authorization.
The form says it may be revoked in writing or electronically through the eBenefits Portal at any time, except to the extent action has already been taken. VA also lists VA Form 10-0525, Revocation of Restriction of the Release of Individually-Identifiable Health Information Through eHEALTH Exchange.
The form has a line for a legal representative's signature and printed name, and says to attach the authority to sign: a Health Care Power of Attorney or Legal Guardian papers.
