What HIE means
An opening paragraph explains HIE, defines opt-out and opt-in, and says completing the form is voluntary and will not affect any benefits to which you may otherwise be entitled.
10-10164
Opt-Out of Sharing Protected Health Information Through Health Information Exchanges
- Agency
- VA
- Revision
- April 2020
- Fillable fields
- 9
- Pages
- 1
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-10164: Opt-Out of Sharing Protected Health Information Through HIE
VA Form 10-10164 is the Department of Veterans Affairs Opt-Out of Sharing Protected Health Information Through Health Information Exchanges. The form says that by completing it, a patient requests to be opted out of health information exchanges (HIE) for treatment purposes. It explains that HIE lets health care professionals and patients access and securely share a patient's protected health information electronically, and lets VA share patient information with community providers and other HIE partners.
The form defines opt-out as none of your health information can be shared through HIE for your treatment except in a life-threatening medical emergency, and opt-in as all of it can be shared. It says health information will continue to be shared for treatment on paper or through fax or other legally allowed means other than HIE. The opposite request, to opt back in, is VA Form 10-10163.
The form is one page: an explanation and privacy statement, the patient's full name and 9-digit Social Security number, the opt-out statement 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 10-10164
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.
Opt-out statement
The patient directs VA to stop electronic sharing through HIE except in a life-threatening medical emergency, notes that sharing on paper, by fax or other legally allowed means continues, and certifies making the request freely and voluntarily.
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 10-10164
- 1
Read the explanation
The opening text explains what opting out means, including the life-threatening medical emergency exception.
- 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 opt-out statement
By signing, the patient directs VA to opt them out of electronic sharing of their health information with HIE partners.
- 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 10-10164 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-out decision will be in effect unless and until it is cancelled by authorizing VA to opt the patient in to HIE in writing on VA Form 10-10163.
Opting back in
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 APR 2020 10-10164, matching the April 2020 revision date on VA's page.
Related forms
10-10163
Request for and Permission to Participate in 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 10-10164?
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 10-10164
What does VA Form 10-10164 do?
The form says completing it requests that the patient be opted out of health information exchanges (HIE) for treatment purposes.
Is any health information still shared after opting out?
The form says it can still be shared through HIE in a life-threatening medical emergency, and will continue to be shared for treatment on paper or through fax or other legally allowed means other than HIE.
Can Active Duty Servicemembers opt out?
The form says: If you are an Active Duty Servicemember, DoD may not permit you to Opt-out of HIE.
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 back in later?
The form points to VA Form 10-10163, 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).