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Agency Information Collection (Request for and Authorization To Release Medical Records or Health Information) Activities Under OMB Review

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In compliance with the Paperwork Reduction Act (PRA) of 1995 (44 U.S.C. 3501-3521), this notice announces that the Veterans Health Administration (VHA), Department of Veterans Affairs, will submit the collection of information abstracted below to the Office of Management and Budget (OMB) for review and comment. The PRA submission describes the nature of the information collection and its expected cost and burden and includes the actual data collection instrument.


Comments must be submitted on or before November 19, 2012.


Submit written comments on the collection of information through; or to VA's OMB Desk Officer, OMB Human Resources and Housing Branch, New Executive Office Building, Room 10235, Washington, DC 20503 (202) 395-7316. Please refer to “OMB Control No. 2900-0260” in any correspondence.


Crystal Rennie, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420, (202) 632-7492, fax (202) 632-7583 or email Please refer to “OMB Control No. 2900-0260.”



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 HealtheVet (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 HealtheVet.

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.

An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The Federal Register Notice with a 60-day comment period soliciting comments on this collection of information was published on July 19, 2012 at pages 42555-42556.

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: October 15, 2012.

By direction of the Secretary.

William F. Russo,

Deputy Director, Office of Regulations Policy and Management, Office of the General Counsel, Department of Veterans Affairs.

[FR Doc. 2012-25747 Filed 10-18-12; 8:45 am]