Privacy Act information
The authority for the form, including Title 38, U.S.C., HIPAA 45 CFR Parts 160 and 164, 5 U.S.C. 552a and 38 U.S.C. 5701, and a note that giving the SSN is voluntary but is used to locate records for release.
10-252
Authorization to Release Protected Health Information to State/Local Public Health Authorities
- Agency
- VA
- Revision
- May 2020
- Fillable fields
- 7
- Pages
- 1
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-252: Authorization to Release Health Information to Public Health Authorities
VA Form 10-252 is the Veterans Health Administration (VHA) Authorization to Release Protected Health Information to State/Local Public Health Authorities. The patient signs it to authorize their VA health care facility to release health information related to immunizations for public health purposes to State and Local Public Health Authorities when reporting is desired by the State.
The form is one page. It covers immunization records from the electronic health record, including those created after the date of signature, and says the authorization remains in effect for ten (10) years unless it is revoked in writing. VA's page lists it under Health care and Records.
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 10-252
Patient identification
Last, first and middle name, printed, the birth date in mm/dd/yyyy format and the last 4 digits of the SSN.
Requestor and information requested
Both are preprinted: State and Local Public Health Authorities, and immunization records from the electronic health record, including those created after the date of signature.
Authorization terms
The release covers existing and future immunization records, lasts ten (10) years, and can be revoked in writing except to the extent action has already been taken. It also notes that records redisclosed by the recipients may no longer be protected.
Certification and signature
A statement that the request is made freely, voluntarily and without coercion and that the information is accurate and complete, then the Signature of Patient and Date lines.
How to fill out VA Form 10-252
- 1
Print the patient's full name
The form asks for last, first and middle name and says to print them.
- 2
Add the birth date and last 4 SSN
Enter the birth date as mm/dd/yyyy. The Privacy Act text says the SSN is used to locate records for release.
- 3
Read the authorization text
It explains what is released, to whom, for how long and how to revoke it.
- 4
Sign and date it
Sign the Signature of Patient line and enter the date.
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Where it goes
No mailing address
The form prints no mailing address. It names the patient's VA health care facility as the one releasing the records.
Revoking it
The form says the authorization may be revoked in writing at any time, and the revocation is effective upon receipt by the Release of Information Unit at the VA health care facility.
Edition
The PDF footer reads VA FORM MAY 2020 10-252. VA's form page lists a form revision date of November 2020.
Related forms
10-259
Revocation of Authorization for Release of Release of Individually-Identifiable Health Information
15 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
10-0527
Request and Authorization to Release Protected Health Information to the Choice/PC3 Program
9 fields, 1 page
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
Who uses VA Form 10-252?
The form names the patient, the VA facility that releases the records and the authorities that receive them.
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Questions about Form 10-252
What does VA Form 10-252 authorize?
The form says it authorizes the patient's VA health care facility to release health information related to immunizations for public health purposes to State and Local Public Health Authorities when reporting is desired by the State.
Does it cover future immunization records?
Yes. The form says it covers the immunization records that exist upon signing and immunization records that may be created in the future.
How long does the authorization last?
The form says it remains in effect for ten (10) years.
Does signing affect VA treatment or benefits?
The form says VHA may not condition treatment, payment, enrollment or eligibility to VA benefits on signing the authorization.
Is giving the SSN required?
The Privacy Act text says disclosure, including the SSN, is voluntary. It also says that if the information is not furnished completely and accurately, VHA will be unable to report to public health authorities.
Can the authorization be revoked?
Yes. The form says it may be revoked in writing at any time except to the extent that action has already been taken to comply with it.