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Proposed Information Collection (Request for and Authorization To Release Medical Records or Health Information) Activity: Comment Request

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The Veterans Health Administration (VHA) is announcing an opportunity for public comment on the proposed collection of certain information by the agency. Under the Paperwork Reduction Act (PRA) of 1995, Federal agencies are required to publish notice in the Federal Register concerning each proposed collection of information, including each proposed revision of a currently approved collection, and allow 60 days for public comment in response to the notice. This notice solicits comments on information needed to obtain a patient written consent to disclose medical records or health information to individuals or third parties.


Written comments and recommendations on the proposed collection of information should be received on or before September 17, 2012.


Submit written comments on the collection of information through the Federal Docket Management System (FDMS) at; or to Cynthia Harvey-Pryor, Veterans Health Administration (10P7BFP), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420 or email: Please refer to “2900-0260” in any correspondence. During the comment period, comments may be viewed online through FDMS.


Cynthia Harvey-Pryor (202) 461-5870 or Fax (202) 273-9387.


Under the PRA of 1995 (Pub. L. 104-13; 44 U.S.C. 3501-3521), Federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor. This request for comment is being made pursuant to Section 3506(c)(2)(A) of the PRA.

With respect to the following collection of information, VHA invites comments on: (1) Whether the proposed collection of information is necessary for the proper performance of VHA's functions, including whether the information will have practical utility; (2) the accuracy of VHA's estimate of the burden of the proposed collection of information; (3) ways to enhance the quality, utility, and clarity of the information to be collected; and (4) ways to minimize the burden of the collection of information on respondents, including through the use of automated collection techniques or the use of other forms of information technology.


a. Request for and Authorization to Release Medical Records or Health Information, VA Form 10-5345.

b. Individual's Request for a Copy of their Own Health Information, VA Form 10-5345a.

c. My Health e Vet (MHV)—Individuals' Request for a Copy of Their Own Health Information, VA Form 10-5345a-MHV.

d. Restriction of the Release of Individually-Identifiable Health Information through Nationwide Health Information Network (NwHIN), VA Form 10-0525a.

e. Request for and Authorization to Release Protected Health Information to Nationwide Health Information Network, VA Form 10-0485.

OMB Control Number: 2900-0260.

Type of Review: Revision of a currently approved collection.


a. VA Form 10-5345 is used to obtain a written consent from patients before information concerning his or her treatment for alcoholism or alcohol abuse, drug abuse, sickle cell anemia, or infection with the human immunodeficiency virus (HIV) can be disclosed to private insurance companies, physicians and other third parties.

b. Patients complete VA Form 10-5345a to request a copy of their health information maintained at Department of Veterans Affairs.

c. VA Form 10-5345a-MHV is completed by individuals requesting their health information electronically through My Health e Vet.

d. VA Form 10-0525a is completed by individuals to restrict the sharing their electronic health information through the NWHIN.

e. VA Form 10-0485 is used to electronically exchange protected health information between VA and approved Nationwide Health Information Network participants.

Affected Public: Individuals or households.

Estimated Total Annual Burden

a. VA Form 10-5345—10,000 hours.

b. VA Form 10-5345a—15,000 hours.

c. VA Form 10-5345a-MVH—35,000 hours.

d. VA Form 10-0525a—50 hours.

e. VA Form 10-0485—500 hours.

Estimated Average Burden Per Respondent—2 minutes for VA Form 10-5345 and 3 minutes for VA Forms 10-5345a, 10-5345a-MVH, 10-0525a, 10-0485.

Frequency of Response: On occasion.

Estimated Number of Respondents:

a. VA Form 10-5345—300,000.

b. VA Form 10-5345a—300,000.

c. 10-5345a-MVH—700,000.

d. VA Form 10-0525a—1,000.

e. VA Form 10-0485—10,000.

Dated: July 13, 2012.

By direction of the Secretary.

Denise McLamb,

Program Analyst, Enterprise Records Service.

[FR Doc. 2012-17506 Filed 7-18-12; 8:45 am]