VA Form 10-259: Revoke VA Health Information Release – VA Form 10-259: Revocation of Authorization for Release of Individually-Identifiable Health Information is a key document for U.S. veterans and VA health care users who want to stop the Department of Veterans Affairs (VA) from sharing their protected health information with non-VA entities.
This form helps protect your privacy under HIPAA rules by formally revoking previous authorizations.
What Is VA Form 10-259?
VA Form 10-259 is officially titled “Revocation of Authorization for Release of Individually-Identifiable Health Information.” Its purpose is to allow patients to discontinue the release of their protected health information (PHI) from the VA to outside or non-VA entities.
The form, revised in March 2021, is a short, one-page document designed specifically for revoking prior consents, such as those given via VA Form 10-5345 (Request for and Authorization to Release Health Information).
It applies to scenarios like:
- Immunization reporting
- Specific prior authorizations (e.g., referencing a dated VA Form 10-5345)
- Other specified releases
Why You Might Need to Use VA Form 10-259?
Veterans may want to revoke authorization for several reasons:
- Concerns about privacy and data sharing with third-party providers or insurers
- Changing preferences after initially authorizing release
- Limiting information shared for non-treatment purposes
- Controlling how their health data is used outside the VA system
Important note: Revoking authorization does not affect your VA health care, benefits, or relationship with VA providers. It only stops future releases of the specified information to non-VA entities. Information already shared before revocation may still be used as permitted.
How to Fill Out VA Form 10-259 Step by Step?
Filling out the form is straightforward:
- Patient Information: Print your full name (last, first, middle) and date of birth (MM/DD/YYYY).
- Revocation Section:
- Check the appropriate box: Immunization reporting, a specific VA Form 10-5345 with date, or “Other” (describe).
- Review the statements confirming you understand the effects of revocation.
- Signature: Sign as the patient or legal representative. If a representative signs, attach proof of authority (e.g., health care power of attorney).
- Date the form.
Keep a copy for your records. The form clearly states that the revocation is explained and that it only affects future disclosures.
How to Submit VA Form 10-259?
Submit the completed form to your local VA health facility’s Release of Information (ROI) Unit or medical records office. Options typically include:
- In person (recommended for confirmation)
- By mail
- By fax (check with your facility)
Contact your specific VA medical center for exact submission details, as processes can vary by location. Revocation generally becomes effective upon receipt by the ROI Unit.
Download VA Form 10-259 PDF
Official Download:
Download VA Form 10-259 (PDF) – Official VA Website
Always use the latest version from the official VA website to ensure compliance.
Related VA Forms and Privacy Options
- VA Form 10-5345: Primary form for requesting or authorizing release of health information (the one you may be revoking).
- VA Form 10-5345a: For requesting your own records.
- Other privacy options exist for health information exchanges (e.g., eHealth Exchange opt-out forms like VA Form 10-10164).
For research-related authorizations, separate revocation processes may apply.
Frequently Asked Questions About VA Form 10-259
Does submitting this form stop all sharing?
No. It only revokes specific authorizations for non-VA releases. Emergency situations or certain required disclosures may still occur as permitted by law.
Can a family member or representative submit it?
Yes, with proper legal documentation attached.
Will this impact my VA benefits?
No. The form explicitly states that revocation has no effect on your care or benefits.
How do I know it was received?
Submit in person for immediate confirmation or request acknowledgment when mailing.
Protecting Your VA Health Information
Understanding and using forms like VA Form 10-259 empowers veterans to maintain control over their sensitive health data. Always consult your VA facility’s ROI office or a VA privacy officer with specific questions about your records.
For the most current information, visit the official VA forms page or contact your local VA medical center directly.
This article is for informational purposes only and is not legal advice. Policies can change; verify details on VA.gov.