VA Form 10-0525a Restriction of the Release of Individually-Identifiable

RESTRICTION OF THE RELEASE OF INDIVIDUALLY-IDENTIFIABLE HEALTH INFORMATION
THROUGH NATIONWIDE HEALTH INFORMATION NETWORK (NwHIN)
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 Nationwide Health Information Network (NwHIN).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.

Purpose: 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 NwHIN.
Patient Full Name
Last: (print)

First:

Middle:

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 NwHIN 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
NwHIN.
CHOOSING YOUR RESTRICTIONS :
Indicate which non-VA health care provider organizations participating in NwHIN 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 NwHIN even if you later
sign an authorization.
VA FORM
DEC 2011

10-0525a

Kaiser Permanente
Med Virginia
Inland Northwest Health Services
Multicare
South Carolina Health Information Exchange
Indiana Health Information Collaborative
Western New York HealtheLink
Community Health Information Collaborative
Utah Health Information Network
North Carolina Healthcare Information and Communications Alliance

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
NwHIN. 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 NwHIN.
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.

Signature of Patient

Signature of Legal Representative (if applicable)

Date

To Sign for Patient (Attach authority to sign: Health Care Power of Attorney or Legal Guardian

Date

Name of Legal Representative (please print)

Date

VA FORM
DEC 2011

10-0525a