Va Form 10-0484 - Revocation For Release Of Individually-Identifiable Health Information
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1Revocation for Release of Individually-Identifiable Health Information
Purpose: Revocation of electronic exchange of individually-identifiable health information between the Department
of Veterans Affairs (VA) and VA Approved Nationwide Health Information Network Participants.
Patient Full Name (print):
Last four digits of SSN:
REVOCATION:
I am requesting to discontinue my participation in the electronic exchange of my health information.
1.
I understand that you will no longer share any of my health information with VA Approved Nationwide Health
2.
Information Network Participants.
I understand that information already exchanged between both parties prior to this revocation will continue
3.
to be used as discussed in the authorization I signed when I elected to participate in this electronic exchange of
my health information.
I understand that withdrawing from this program does not change my relationship with my health care
4.
providers, my future care, or have any effect on my VA benefits.
I understand that the VA will respond to this revocation in writing informing me that they have confirmed my
5.
request and the effective date of this revocation.
RE-ENROLL: I understand if I decide to re-enroll in the project at a later date, I will be required to start the
enrollment process all over again.
SIGNATURE: This revocation has been explained to me and I have been given the opportunity to ask questions.
I hereby revoke the sharing of individually-identifiable health information as described in this form.
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)
Date
VA FORM
10-0484
JAN 2011
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