What HIE means
An opening paragraph explains HIE, defines opt-in and opt-out, and says completing the form is voluntary and will not affect any benefits to which you may otherwise be entitled.
10-10163
Request for and Permission to Participate in Sharing Protected Health Information through Health Information Exchanges
- Agency
- VA
- Revision
- October 2019
- Fillable fields
- 9
- Pages
- 1
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-10163: Request to Participate in Sharing Health Information Through HIE
VA Form 10-10163 is the Department of Veterans Affairs Request for and Permission to Participate in Sharing Protected Health Information through Health Information Exchanges. The form says that by completing it, a patient authorizes VA to share their protected health information through VA health information exchanges (HIE), which let health care professionals and patients access and securely share a patient's medical information electronically with community providers and other HIE partners.
The form is for patients who previously chose to opt out of HIE. It says completing it cancels the previous opt-out request. It defines opt-in as all of your health information can be shared through HIE, and opt-out as none of it can be shared through HIE except in a life-threatening medical emergency. The opposite request is VA Form 10-10164.
The form is one page: an explanation and privacy statement, the patient's full name and 9-digit Social Security number, the participation request and signatures. 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 10-10163
Privacy statement
The information is part of the Privacy Act system of records Health Information Exchange-VA, 168VA005, and is solicited under Title 38, U.S.C. 501.
Full name and SSN
Last name in print, first name, middle name and the 9-digit Social Security number.
Participation request
The patient requests and authorizes VA to release their protected health information through HIE for treatment, cancels the earlier opt-out, and certifies making the request freely, voluntarily and without coercion.
Signatures
Signature of patient and date, signature of legal representative and date if applicable, both signed in ink, and the legal representative's printed name.
How to complete VA Form 10-10163
- 1
Read the explanation
The opening text explains what opting in means and that it cancels the previous opt-out request.
- 2
Print your name and SSN
The form says VA uses the Social Security Number to electronically locate patient records, so it asks for your complete and accurate SSN.
- 3
Read the participation request
By signing, the patient authorizes the release through HIE and certifies the request is made freely and voluntarily.
- 4
Sign in ink and date
Sign the patient signature line in ink and enter the date as MM/DD/YYYY.
- 5
If a representative signs
The legal representative signs in ink, dates it, prints their name and attaches the Health Care Power of Attorney or Legal Guardian authority.
Why fill Form 10-10163 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 changing your choice
Where to send it
The PDF does not print a mailing address, fax number or submission method for this form.
How long it lasts
The form says the opt-in request will be in effect unless and until the patient opts out in writing on VA Form 10-10164.
Opting out again
The form says to contact the Release of Information Office at the VA Medical Center where you receive treatment or call the Health Eligibility Center (HEC) Call Center at 1-877-771-VLER (8537).
Edition
The PDF footer reads VA FORM OCT 2019 10-10163. VA's page lists a form revision date of October 2021.
Related forms
10-10164
Opt-Out of Sharing Protected Health Information Through Health Information Exchanges
9 fields, 1 page
10-0525a
Restriction of the Release of Individually-Identifiable Health Information Through eHEALTH Exchange
25 fields, 2 pages
10-0525
Revocation of Restriction of the Release of Individually-Identifiable Health Information Through eHEALTH Exchange
9 fields, 1 page
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
Who uses VA Form 10-10163?
The form describes who completes it, who may sign for the patient and who acts on it.
Official sources and the blank
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Questions about Form 10-10163
What does VA Form 10-10163 do?
The form says it opts the patient in to the electronic exchange of health information for treatment purposes and cancels the opt-out request they previously submitted.
What is the difference between opt-in and opt-out?
The form says opt-in means all of your health information can be shared through HIE, and opt-out means none of it can be shared through HIE except in a life-threatening medical emergency.
Is completing the form voluntary?
Yes. The form says disclosure is voluntary and a decision to complete it will not have any effect on any benefits to which you may otherwise be entitled.
Why does the form ask for my Social Security number?
The form says VA uses the SSN to electronically locate patient records, and VHA will be unable to comply with the request if it is not furnished completely and accurately.
Can someone else sign for the patient?
The form has a line for a legal representative, if applicable, and asks to attach the authority to sign: a Health Care Power of Attorney or Legal Guardian document.
How do I opt out again later?
The form points to VA Form 10-10164, the Release of Information Office at the VA Medical Center where you receive treatment, or the HEC Call Center at 1-877-771-VLER (8537).