Fillable Printable VA Form 10-0490
Fillable Printable VA Form 10-0490
VA Form 10-0490
VA FORM
JUL 2010
10-0490
Page 1 of 2
ACKNOWLEDGEMENT OF RECEIPT OF DEPARTMENT OF VETERANS AFFAIRS
PROTECTED HEALTH INFORMATION BY AFFILIATED EDUCATIONAL INSTITUTIONS
Use when VA Protected Health Information (PHI) is disclosed to an Affiliated Educational Institution for purposes of health care operations
(including education program administration and/or quality assurance activities.
1. Background and Justification
The Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rule requirements in 45 CFR Parts
160 and 164 allow disclosure of Protected Health Information (PHI) without prior written authorization from the individual for
purposes of treatment, payment and health care operations. Education program administration and quality assurance activities
are both considered health care operations and consequently VA PHI may be disclosed to Affiliated Educational Institutions
without prior written authorization from the individual.
VA PHI may be transferred to the Affiliated Educational Institution for health care operations in three distinct ways. First,
shared trainees may submit data directly to the Affiliated Educational Institution. Second, shared faculty members may be
required to submit PHI. Third, there may be direct institution to institution transmission of PHI.
Affiliated Educational Institutions need PHI for the following purposes in the administration of educational programs, quality
assurance activities and other assessments such as those delineated below:
a) To assess the competency of trainees and staff.
b) To assess the number and types of patients from which trainees learn, or that staff members care for.
c) To comply with clinical and/or education accreditation standards.
d) For academic or disciplinary actions involving trainees or staff for which individually-identifiable patient
information is relevant.
e) To assess and improve the quality of care during training and learning activities.
This Acknowledgement will ensure that, when Affiliated Educational Institutions receive VA PHI for purposes of educational
program administration, quality assurance activities or other assessments, they will collect, store and protect this information
according to all applicable HIPAA standards. Although VA facilities and their Affiliated Educational Institutions are encouraged
to exchange de-identified data whenever such data is sufficient, Affiliated Educational Institutions may either choose to or be
required to use VA PHI.
NOTE: If the VA and Affiliated Educational Institution have committed to exchange only de-identified data (whether in
electronic or paper format) then this agreement is not applicable and does not need to be executed.
2. Ownership of VA PHI
When VA PHI is disclosed to Affiliated Educational Institutions, either directly, or through trainees or faculty members, it is
considered a permitted disclosure for health care operations under the Privacy Rule. Copies of data disclosed to the Affiliated
Educational Institution become the property of that Affiliated Educational Institution and are no longer considered a part of a VA
Privacy Act System of Records. Original data maintained by VA will remain VA's data.
3. Use and Disclosure of VA PHI
Unless otherwise limited herein, the Affiliated Educational Institution receiving VA PHI disclosures may use or disclose this
data for its own purposes of health care operations or other legal requirements. Such use or disclosure must be in accordance with
applicable Privacy and Security Rule requirements. Both VA and Affiliated Educational Institutions will observe the “minimum
necessary” requirements of the Privacy Rule when making requests or disclosures.
VA FORM
JUL 2010
10-0490
Page 2 of 2
4. Definition of VA PHI
For the purpose of this document, VA PHI refers only to individually-identifiable patient information as defined
under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
5. Effective Date
This Acknowledgement shall be effective on the date signed by all parties.
6. Review Date
The provisions of this agreement will be reviewed by VA every two years from the Effective Date to determine the
applicability of the agreement based on the relationship of the parties at the time of the review.
VHA FACILITY NAME
AFFILIATED EDUCATIONAL
INSTITUTION
Signature of Dean, Associate Dean or Equivalent
Responsible Official for the Affiliated Educational
Institution or Program
Date of Signature
Typed Title of Individual Signing Above
Typed Name of Individual Signing Above
Signature of VA Medical Center Director
Typed Name of Individual Signing Above
Typed Title of Individual Signing Above
Date of Signature
Signature of Responsible Legal Official for the Affiliated
Educational Institution or Program
Date of Signature
Typed Title of Individual Signing Above
Typed Name of Individual Signing Above
Signature of VA Designated Education Official
Typed Name of Individual Signing Above
Typed Title of Individual Signing Above
ACKNOWLEDGEMENT OF RECEIPT OF DEPARTMENT OF VETERANS AFFAIRS
PROTECTED HEALTH INFORMATION BY AFFILIATED EDUCATIONAL INSTITUTIONS
Date of Signature
