Information Collection

Request for and Authorization to Release Medical Records or Health Information, etc

IC 28503 under ICR 201206-2900-012 · OMB 2900-0260.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0260 can be found here:

Documents and Forms

Document Name Document Type
Form 10-5345a Request for and Authorization to Release Medical Records or Health Information, etc Form
10-5345a Individuals' Request for a Copy of Their Own Health Info vha-10-5345a-fill.pdf www.va.gov/vaforms/medical/pdf/vha-10-5345a-fill.pdf Form
VA Form 10-5345a-M Individuals' Request for a Copy of Their Own Health Info 10-5345a-MHV V2.pdf www.va.gov/vaforms/medical/pdf/vha-10-5345a-MHV-fill.pdf Form
VA Form 10-0485 Request for and Authorization to Release Protected Healt 10-0485 3-13 (2).pdf eBenefits Web Portal also iMedConsent Form
VA Form 10-5345 Request for and Authorization to Release Medical Records vha-10-5345-fill.pdf eBenefits Web Portal also iMedConsent Form
VA Form 10-0525a Restriction of the Release of Individually-Identifiable 10-0525a 12-2011.pdf eBenefits Web Portal also iMedConsent Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for and Authorization to Release Medical Records or Health Information, etc	Agency IC Tracking Number:	2900-0260

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 164 45 CFR 160 38 CFR 1.577

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-5345a	Individuals' Request for a Copy of Their Own Health Information	vha-10-5345a-fill.pdf	http://www.va.gov/vaforms/medical/pdf/vha-10-5345a-fill.pdf	Yes	No	Fillable Printable
Form	VA Form 10-5345a-MHV	Individuals' Request for a Copy of Their Own Health Information - My HealtheVet (MHV)	10-5345a-MHV V2.pdf	http://www.va.gov/vaforms/medical/pdf/vha-10-5345a-MHV-fill.pdf	Yes	No	Fillable Printable
Form	VA Form 10-0485	Request for and Authorization to Release Protected Health Information to Nationwide Health Information Network	10-0485 3-13 (2).pdf	eBenefits Web Portal also iMedConsent	Yes	Yes	Fillable Fileable
Form	VA Form 10-5345	Request for and Authorization to Release Medical Records or Helath Information	vha-10-5345-fill.pdf	eBenefits Web Portal also iMedConsent	Yes	Yes	Fillable Fileable
Form and Instruction	VA Form 10-0525a	Restriction of the Release of Individually-Identifiable Health Information through Nationwide Health Information Network (NwHIN)	10-0525a 12-2011.pdf	eBenefits Web Portal also iMedConsent	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,311,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 28 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,311,000	11,000	0	1,300,000
Annual IC Time Burden (Hours)	60,550	550	-5,000	65,000
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.