This collection is approved for a period of two years, as soon as possible VA shall revise the collection to incorporate signature recognition technology in order to provide respondents with a complete electronic process for the completion and submission of electronic forms.
Inventory as of this Action
Requested
Previously Approved
01/31/2010
36 Months From Approved
02/29/2008
1,780,000
0
1,000,000
59,333
0
33,333
0
0
0
These forms are used to obtain written patient consent for release of medical reocrds to individuals and third parties when the information is considered "protected", the information is covered by confidentiality, privacy or HIPAA statutes, or the individual requests copies of their own records.
US Code:
38 USC 7332
Name of Law: Confidentiality of certain medical records
US Code:
38 USC 5701
Name of Law: Confidential nature of claims
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Form 10-5345 Request for and Authorization to Release Medical Records or Health Information, Individual's Request for a Copy of Their Own Health Information
2900-0260.doc
Request for and Authorization to Release Medical Records or Health Information, Individual's Request for a Copy of Their Own Health Information