REQUEST FOR AND AUTHORIZATION TO RELEASE HEALTH INFORMATION

REQUEST FOR AND AUTHORIZATION TO RELEASE HEALTH INFORMATION
PRIVACY ACT STATEMENT:

The information requested on this form is solicited under Title 38 U.S.C. The form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164; 5 U.S.C. 552a; and 38 U.S.C. 5701 and 7332 that you specify. Your disclosure of the information requested on this form is voluntary. However, if information needed to locate records for release is not furnished completely and accurately, VA will be unable to comply with the request. The Veterans Health Administration may not condition the provision of treatment, payment, enrollment in the VA Health Care Program, or eligibility for benefits on the signing of an authorization, except for research-related treatment where an authorization for the use or disclosure of individually- identifiable health information for such research is required. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in the Privacy Act system of records notices identified as 24VA10A7 "Patient Medical Record - VA", 08VA05 "Employee Medical File System Records (Title 38)-VA" and in accordance with the Notice of Privacy Practices. VA may also use this information to identify Veterans and person claiming or receiving VA benefits and their records, and for other purposes authorized or required by law.
Name*

First NameMiddle NameLast Name
Date of Birth (mm/dd/yyyy)*

MonthDayYear
DOB for PDF

MonthDayYear
Date
Patient's Mailing Address (including City, State and Zip Code)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Purpose(s) or Need: Information is to be used by the requestor for

TreatmentBenefitsLegalEmploymentOther (Please specify below)
Information Requested: Check applicable box(es) and state the extent or nature of information to be provided

Health Summary (Prior 2 Years)
Check applicable box and state the extent or nature of information to be provided

Patient Medical Records (Dates)
Date Range of Patient Medical Records
Check applicable box and state the extent or nature of information to be provided

Inpatient Discharge Summary (Dates):
Date Range of Inpatient Discharge Summary
Check applicable box and state the extent or nature of information to be provided

Progress Notes
Check applicable box and state the extent or nature of information to be provided

Specific Clinics (Name and Date Range)
Name and Date Range of Specific Clinics
Check applicable box and state the extent or nature of information to be provided

Specific Providers (Name and Date Range)
Name and Date Range of Specific Providers
Check applicable box and state the extent or nature of information to be provided

Date Range
Date Range
Check applicable box and state the extent or nature of information to be provided

Operative/Clinical Procedures (Name and Date)
Name and Date of Operative/Clinical Procedures
Check applicable box and state the extent or nature of information to be provided

Lab Results
Check applicable box and state the extent or nature of information to be provided

Specific Tests (Name and Date)
Name and Date of Specific Tests
Check applicable box and state the extent or nature of information to be provided

Date Range
Lab Results Date Range
Check applicable box and state the extent or nature of information to be provided

Radiology Reports
Name and Date of Radiology Reports
Check applicable box and state the extent or nature of information to be provided

List of active medications
List of active medications
Check applicable box and state the extent or nature of information to be provided

Vaccination
Dose, Lot Number, Date and Location
Check applicable box and state the extent or nature of information to be provided

Administrative Records
Description of Administrative Records
Check applicable box and state the extent or nature of information to be provided

Other (Describe)
Other Description
Name

First NameMiddle NameLast Name
DOB for PDF

MonthDayYear
Date
SENSITIVE DIAGNOSES: REVIEW AND, IF APPROPRIATE, COMPLETE WHEN RELEASE IS FOR ANY PURPOSE OTHER THAN TREATMENT.
I request and authorize Department of Veterans Affairs to release the information pertaining to the condition(s) below for the non-treatment purpose(s) listed in this authorization.

Drug AbuseAlcoholism or Alcohol AbuseSickle Cell AnemiaHuman Immunodeficiency Virus (HIV)
I understand that information on these sensitive diagnoses may be released for treatment purposes without me checking the above boxes, and will be released even if the boxes are unchecked unless I indicate by checking the box below that I do not want this information released for this specific disclosure.

I do not want sensitive diagnoses released for treatment purposes under this specific authorization. I realize this does not impact other future requests unrelated to this authorization.
AUTHORIZATION: I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete to the best of my knowledge. I understand that I will receive a copy of this form after I sign it. I may revoke this authorization in writing, at any time except to the extent that action has already been taken to comply with it. Written revocation is effective upon receipt by the Release of Information Unit at the facility housing records. Any disclosure of information carries with it the potential for unauthorized redisclosure, and the information may not be protected by federal confidentiality rules. I understand that the VA health care provider's opinions and statements are not official VA decisions regarding whether I will receive other VA benefits or, if I receive VA benefits, their amount. They may, however, be considered with other evidence when these decisions are made at a VA Regional Office that specializes in benefit decisions.
EXPIRATION: Without my express revocation, the authorization will automatically expire (select one of the following):

After one-time Disclosure, if all needs are satisfiedOn (mm/dd/yyyy) (enter a future date other than date signed by patient)Under the following conditions:
Conditions
(enter a future date other than date signed by patient)

MonthDayYear
(enter a future date other than date signed by patient)

MonthDayYear
Date
Patient Signature

Clear
Use your mouse, touchpad, or touchscreen in the area above to provide your signature.
Patient Signature Date

MonthDayYear
Patient Sig Date for PDF

MonthDayYear
Date
Legal Representative Signature (if applicable)

Clear
Use your mouse, touchpad, or touchscreen in the area above to provide your signature.
Legal Representative Signature Date

MonthDayYear
Legal Representative Date for PDF

MonthDayYear
Date
Print Name of Legal Representative
Relationship to Patient
FOR VA USE ONLY
Date Released

MonthDayYear
Date Released

MonthDayYear
Date
Released By
Should be Empty: