Purpose
A line stating the form revokes authorization for VA to release individually-identifiable health information to an outside or non-VA entity.
10-259
Revocation of Authorization for Release of Release of Individually-Identifiable Health Information
- Agency
- VA
- Revision
- March 2021
- Fillable fields
- 15
- Pages
- 1
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-259: Revocation of Authorization for Release of Health Information
VA Form 10-259 is the Revocation of Authorization for Release of Individually-Identifiable Health Information. The form states its purpose as revocation of authorization for the Department of Veterans Affairs (VA) to release individually-identifiable health information to an outside or non-VA entity.
The form is one page. The patient names what to stop releasing: immunization reporting, a VA 10-5345 authorization with its date, or another release. It lists what the revocation means, then has signature lines for the patient and, if applicable, a legal representative. 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 10-259
Patient identification
Last name, printed, first and middle name, and the date of birth as MM/DD/YYYY.
Item 1: what to revoke
Check boxes for immunization reporting, a VA 10-5345 with the date it was signed, and Other with space to describe it.
Items 2 to 4: what the revocation means
VA stops sharing with the outside entity, information already released continues to be used as the original authorization says, and the revocation does not change care, providers or VA benefits.
Signatures
Signature of patient and date, signature of legal representative and date if applicable, and the representative's printed name.
How to fill out VA Form 10-259
- 1
Print the patient's name and birth date
Enter last, first and middle name and the date of birth as MM/DD/YYYY.
- 2
Choose what to revoke
Check immunization reporting, enter the date of the VA 10-5345 being revoked, or describe another release under Other.
- 3
Read items 2 to 4
They explain what changes and what does not after the revocation.
- 4
Sign and date it
The patient signs and dates it. A legal representative who signs instead also prints their name and attaches the authority to sign.
Why fill Form 10-259 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
Where it goes
No mailing address
The form prints no mailing address and does not say where to send it.
Earlier releases
Item 3 says information already released or shared before the revocation continues to be used as discussed in the authorization the patient signed.
Edition
The footer reads VA FORM MAR 2021 10-259. VA's form page lists a form revision date of March 2021.
Related forms
10-5345
Request for and Authorization to Release Health Information
61 fields, 2 pages
10-252
Authorization to Release Protected Health Information to State/Local Public Health Authorities
7 fields, 1 page
10-5345a
Individuals' Request for a Copy of Their Own Health Information
43 fields, 1 page
10-0525
Revocation of Restriction of the Release of Individually-Identifiable Health Information Through eHEALTH Exchange
9 fields, 1 page
10-10164
Opt-Out of Sharing Protected Health Information Through Health Information Exchanges
9 fields, 1 page
10-0527
Request and Authorization to Release Protected Health Information to the Choice/PC3 Program
9 fields, 1 page
Who uses VA Form 10-259?
The form names the patient, a legal representative and the outside entity.
Official sources and the blank
Do it all with indox
No tool matches that search.
Questions about Form 10-259
What does VA Form 10-259 do?
The form says it revokes authorization for VA to release individually-identifiable health information to an outside or non-VA entity.
Which releases can it revoke?
Item 1 lists immunization reporting, a VA 10-5345 identified by its date, and Other, with space to describe the release.
Does it undo information already shared?
No. The form says information already released or shared before the revocation continues to be used as discussed in the authorization the patient signed.
Does revoking affect VA care or benefits?
Item 4 says withdrawing the authorization does not change the patient's relationship with health care providers or future care, or have any effect on VA benefits.
Can someone sign VA Form 10-259 for the patient?
The form has a line for a legal representative, if applicable, and says to attach the authority to sign: Health Care Power of Attorney or Legal Guardian.