OPT-OUT OF SHARING PROTECTED HEALTH
INFORMATION THROUGH HEALTH
INFORMATION EXCHANGES
By completing this form, you are requesting to be opted out of health information exchanges (HIE) for treatment purposes. HIE
allows health care professionals and patients to access and securely share a patient’s protected health information electronically.
HIE enables VA to share patient information with community providers and other HIE partners. Opt-out means that none of your
health information can be shared through HIE for your treatment except in a life-threatening medical emergency. If you are an
Active Duty Servicemember, DoD may not permit you to Opt-out of HIE. Opt-in means that all of your health information can be
shared through HIE for your treatment. Your disclosure of the information requested on this form is voluntary. A decision to complete
the form will not have any effect on any benefits to which you may otherwise be entitled, however, you will not be able to participate
in HIE. Because VA uses the Social Security Number (SSN) to electronically locate patient records, you need to provide your
complete and accurate SSN in order for us to carry out your request to opt-out.
PRIVACY STATEMENT: Your disclosure of the personal information requested on this form is voluntary. However, if the information
containing the Social Security Number (SSN) (the SSN will be used to locate records) is not furnished completely and accurately, the
Veterans Health Administration (VHA) will be unable to comply with your request. By completing this form, you will be opted out of
the electronic exchange of health information for treatment purposes. Failure to furnish the personal information will not have any
effect on any other benefits to which you may be entitled; however, you will not be opted out of information exchange. Consistent
with the VA Notice of Privacy Practices, VA may also use the information on this form for purposes other than your treatment as
authorized or required by law. The information collected on this form is part of a Privacy Act system of records, “Virtual Lifetime
Electronic Record (VLER)-VA”, 168VA10P2. The personal information requested on this form is solicited under Title 38, U.S.C. 501.
OPT-OUT
By signing this form, I understand that I am directing VA to opt me out of electronic sharing of my health information with HIE
partners. By signing this form, I am agreeing that my health information will no longer be shared electronically with partners through
HIE for their treatment of me except in a life-threatening medical emergency. My health information will continue to be shared for my
treatment on paper or through fax or other legally allowed means other than HIE. I certify that I am making this opt-out request
freely, voluntarily, and without coercion. This opt-out decision will be in effect unless and until I cancel it by authorizing VA to opt me
in to HIE in writing on VA Form 10-10163.
If you decide that you would like to be opted back in to the sharing of your health information, you will need to contact the Release of
Information Office at the VA Medical Center where you receive treatment or call the Health Eligibility Center (HEC) Call Center at
1-877-771-VLER (8537).
VA FORM
April 2020
10-10164
VETERAN’S FULL NAME:
LAST (Print)
FIRST MIDDLE 9-DIGIT SSN
SIGNATURE:
Signature of Patient
Date
Signature of Legal Representative (if applicable)
Date
To Sign for Patient (Attach authority to sign: Health Care Power of Attorney or Legal Guardian)
Name of Legal Representative (please print)
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