View Information Collection (IC)

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

Federal Enterprise Architecture Business Reference Module

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