Fillable Printable VA Form 10-0525a
Fillable Printable VA Form 10-0525a
VA Form 10-0525a
RESTRICTION OF THE RELEASE OF INDIVIDUALLY-IDENTIFIABLE HEALTH INFORMATION
THROUGH eHEALTH EXCHANGE
Restriction of electronic exchange of individually-identifiable health information between the Department
of Veterans Affairs (VA) and Non -VA Health Care Provider Organizations who are participating in the eHealth
Exchange.
Last four digits of SSN:
RESTRICTION REQUEST:
1. You have the right to request the Department of Veterans Affairs (VA)restrict or limit the sharing of your
electronic health information through the eHealth Exchange by designating which non-VA health care
provider organizations you do NOT wish to receive your information.
2. A restriction request may be filed even if you do not have an authorization on file permitting the disclosure
of your health information to non-VA health care provider organizations. However, if no authorization is on
file, your restriction request will be in an inactive status until such time as an authorization is filed.
3. Any restriction request you submit will ONLY apply to the sharing of your electronic health information
through eHealth Exchange.
Middle:
Patient Full Name
Last: (print)
CHOOSING YOUR RESTRICTIONS:
Indicate which non-VA health care provider organizations participating in eHealth Exchange you do NOT
wish to receive your electronic health information.
Make sure you mark all of your choices at this time and that your choices reflect all non-VA health care
organizations that you wish to restrict. Once you submit your restriction request VA will not share your health
information with the selected non-VA health care provider organizations through the eHealth Exchange even if
you later sign an authorization.
Privacy Act and Paperwork Reduction Act Information: The purpose of this form is to capture your request to restrict the
sharing of your electronic health information through the eHealth Exchange. The information requested on this form is solicited
under Title 38 U.S.C. Your disclosure of the information requested on this form is voluntary. However, if the information
including your Social Security Number (SSN), which will be used to locate your records, is not provided completely and
accurately, Department of Veterans Affairs (VA) will be unable to comply with your restriction request. VA may disclose the
information that you put on the form as authorized or required by law. VA may make a “routine use” disclosure of the
information as outlined in the Privacy Act Systems of Records Notice identified 168VA10P2 “Virtual Lifetime Electronic
Record (VLER)-VA” in accordance with the VHA Notice of Privacy Practices. You do not have to provide the information
requested to VA but if you don't, VA will be unable to process your restriction request and the sharing of your electronic health
information will not be restricted. Failure to provide the requested information will not have any affect on any other benefits to
which you may be entitled The Paper Work Reduction Act of 1995 requires VHA to notify you that this information collection is
in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or
sponsor and you are not required to respond to, a collection of information unless it displays a valid Office of Management and
Budget (OMB) number. We anticipate that the time expended by all individuals who must complete this form will average 2
minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.
VA FORM
JUN 2013
10-0525a
First:
OMB Number: 2900-0260
Estimated Burden: 3 minutes
Purpose:
Signature of Patient
SIGNATURE:
1. I request and authorize VA to restrict the release of my individually-identifiable health information for
treatment purposes to the selected non-VA health care provider organization(s) participating in the eHealth
Exchange. I understand in making this selection that none of my VA individually-identifiable health
information will be shared with the selected non-VA health care provider organization(s) through eHealth
Exchange.
2. I understand that this restriction will remain in effect until revoked or replaced. I may revoke this
restriction in writing or electronically through the eBenefits Portal, at any time, except to the extent that
action has already been taken to comply with it.
3. By signing this request, I certify that this request has been made freely, voluntarily and without coercion.
4. I understand that this request supersedes and replaces all previous requests and represents completely ALL
of my restriction choices.
Date
Date
Name of Legal Representative (please print)
Signature of Legal Representative (if applicable)
To Sign for Patient (Attach authority to sign: Health Care Power of Attorney or Legal Guardian
Indiana Health Information Collaborative
Kaiser Permanente
North Carolina Healthcare Information and Communications Alliance
Utah Health Information Network
Community Health Information Collaborative
Western New York HealtheLink
South Carolina Health Information Exchange
Multicare
Inland Northwest Health Services
Med Virginia
VA FORM
JUN 2013
10-0525a
