VA FOREIN Medical Services E.I.N -301168216 R.N.C-1-31-607748

   Secure Fax Number:980.216.6020           Secure Fax Number:980.216.6020

VAFMS MEDICAL RECORDS RELEASE FORM

PRIVACY ACT AND PAPERWORK REDUCTION ACT INFORMATION:

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Act. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless is displays a valid 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 the instructions, gather the necessary facts and fill out this form. The execution of this form does not authorize the release of information other than that specifically described below. The information requested on this form is solicited under Title 38 U.S.C. The form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164; 5 U.S.C. 552a; and 38 U.S.C. 5701 and 7332 that you specify. Your disclosure of the information requested on this form is voluntary. However, if information needed to locate records for release is not furnished completely and accurately, VA Foreign Medical Services will be unable to comply with the request. The VA Foreign Medic al Services may not condition the provision of treatment, payment, enrollment in the VA Foreign Medical Services Program, or eligibility for benefits on the signing of an authorization, except for research-related treatment where an authorization for the use or disclosure of individuallyidentifiable health information for such research is required. VA Foreign Medical Services may disclose the information that you put on the form as permitted by law. VA Foreign Medical Services may make a "routine use" disclosure of the information as outlined in the Privacy Act system of records notices identified as VA FOREIGN MEDICAL SERVICES: REQUEST FOR AND AUTHORIZATION TO RELEASE HEALTH INFORMATION 08VA05 "Employee Medical File System Records (Title 38)-VA" Foreign Medical Services and in accordance with the Notice of Privacy Practices. VA Foreign Medical Services may also use this information to identify Veterans and person claiming or receiving VA benefits and their records, and for other purposes authorized or required by law.
REQUEST FOR AND AUTHORIZATION TO RELEASE HEALTH INFORMATION
I understand that information on these sensitive diagnoses may be released for treatment purposes without me checking the above boxes, and will be released even if the boxes are unchecked unless I indicate by checking the box below that I do not want this information released for this specific disclosure.
AUTHORIZATION: I certify that this request has been made freely, voluntarily and without coercion and that the information given above is
accurate and complete to the best of my knowledge. I understand that I will receive a copy of this form after I sign it. I may revoke this
authorization in writing, at any time except to the extent that action has already been taken to comply with it. Written revocation is effective upon
receipt by the Release of Information Unit at the facility housing records. Any disclosure of information carries with it the potential for
unauthorized redisclosure, and the information may not be protected by federal confidentiality rules.
I understand that the VA Foreign Medical Services care provider's opinions and statements are not official VA Foreign Medical Services decisions regarding whether I will receive other VA
benefits or, if I receive VA benefits, their amount. They may, however, be considered with other evidence when these decisions are made at a VA
Regional Office that specializes in benefit decisions.