Fillable Printable VA Form 10-0525

VA Form 10-0525

REVOCATION OF RESTRICTION FOR RELEASE OF INDIVIDUALLY-IDENTIFIABLE HEALTH

INFORMATION THROUGH eHEALTH EXCHANGE

Purpose: Revocation of all restrictions requests on the electronic exchange of individually-identifiable health information

between the Department of Veteran Affairs (VA) and non-VA health care provider organizations participating in the eHealth

Exchange. By revoking all restrictions requests, the sharing of your electronic health information to non-VA health care

provider organizations through the eHealth Exchange is no longer restricted or limited in any way.

Patient Full Name

Last: (print)

First: Middle:

Last four digits of SSN:

REVOCATION OF RESTRICTION REQUEST:

1. I request and authorize VHA to revoke ALL restrictions I previously submitted on the release of my individually

identifiable health information for treatment purposes to non-VA health care provider organizations through the

eHealth Exchange.

2. By signing this request, I certify that this revocation of restrictions request has been made freely, voluntarily and

without coercion.

3. I understand that revocation of my previous restrictions will result in my VA electronic individually- identifiable

health information being shared with all non-VA health care provider organization(s) through eHealth Exchange.

SIGNATURE: This revocation of my restriction request has been explained to me. I hereby revoke all of my

restrictions.

Signature of Patient Date

Signature of Legal Representative (if applicable)

Date

Name of Legal Representative (please print)

VA FORM

FEB 2014

10-0525