Privacy Act information
Says the form authorizes release only of the information described, that disclosure is voluntary, and that VHA may not condition treatment, payment, enrollment or eligibility on signing the authorization.
10-0527
Request and Authorization to Release Protected Health Information to the Choice/PC3 Program
- Agency
- VA
- Revision
- June 2015
- Fillable fields
- 9
- Pages
- 1
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-0527: Authorization to Release Health Information to the Choice/PC3 Program
VA Form 10-0527 is the U.S. Department of Veterans Affairs Request and Authorization to Release Protected Health Information to the Choice/PC3 Program. On it, a patient authorizes the Veterans Health Administration (VHA) and its Contractor to release protected health information, for treatment purposes only, to non-VA providers participating in the Choice/PC3 Program Network.
The form says the information requested is pertinent health information from the health record for the patient's referral or appointment. The authorization covers some diagnoses protected by 38 U.S.C. 7332 and lasts two years from the date of signature unless revoked in writing.
The form is one page: a Privacy Act notice, the patient's details, the authorization text and a signature line. 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 10-0527
Patient and requestor details
The patient's last, first and middle name, birth date (mm/dd/yyyy), last four digits of the Social Security number and a Requestor Name line.
Information requested
Pre-printed as pertinent health information from the health record for the patient's referral or appointment.
Scope of the authorization
Release may include a diagnosis of sickle cell anemia, treatment of or referral for drug or alcohol abuse, or treatment of or testing for HIV infection, covering current diagnoses and ones acquired in the future.
Duration, revocation and signature
The two-year term, the written revocation rule, a note on re-disclosure, the certification that the request is made freely and voluntarily, and the patient's signature and date.
How to fill out VA Form 10-0527
- 1
Read the authorization text
Read the Privacy Act notice and the authorization paragraphs, which say what is released, to whom, and for how long.
- 2
Enter the patient's details
Print the patient's name, birth date in mm/dd/yyyy format and the last four digits of the Social Security number.
- 3
Add the requestor name
Fill in the Requestor Name line. The form does not explain who the requestor is.
- 4
Sign and date it
The patient signs and dates the form, certifying that the request is made freely, voluntarily and without coercion and that the information given is accurate and complete.
Why fill Form 10-0527 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
Submitting it and revoking it
Where to send it
The form and VA's form page do not print a mailing address, fax number or online way to submit it.
How long it lasts
The form says the authorization remains in effect for two years from the date of signature.
Revoking it
The form says it may be revoked in writing at any time, except where action has already been taken, and that the revocation is effective upon receipt by the Release of Information Unit at the patient's VA health care facility.
Edition
The edition is dated JUN 2015, and the footer reads 10-0527-CHOICE. The form does not print an OMB number.
Related forms
10-5345
Request for and Authorization to Release Health Information
61 fields, 2 pages
10-5345a
Individuals' Request for a Copy of Their Own Health Information
43 fields, 1 page
10-259
Revocation of Authorization for Release of Release of Individually-Identifiable Health Information
15 fields, 1 page
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
10-10172
Community Care Provider—Request for Service
56 fields, 2 pages
Who uses VA Form 10-0527?
The form names who signs the authorization and who releases and receives the information.
Official sources and the blank
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Questions about Form 10-0527
What is VA Form 10-0527 used for?
The form says the patient authorizes VHA and its Contractor to release protected health information, for treatment purposes only, to non-VA providers participating in the Choice/PC3 Program Network.
How long does the authorization last?
The form says it remains in effect for two years from the date of signature.
Does signing affect my VA treatment?
The Privacy Act notice says VHA may not condition treatment, payment, enrollment or eligibility on signing the authorization.
What kinds of information does it cover?
The form says the release may include a diagnosis of sickle cell anemia, treatment of or referral for drug or alcohol abuse, or treatment of or testing for HIV infection, including diagnoses protected by 38 U.S.C. 7332 and ones acquired in the future.
How is the authorization revoked?
In writing, at any time, except where action has already been taken. The form says the revocation is effective when the Release of Information Unit at the VA health care facility receives it.
Is the information still protected after release?
The form says that once VA discloses the information it may no longer be protected by federal law, and that the recipients may re-disclose it without further written authorization.