VA Form FL-10-212 Fillable: Request Medical Records Guide

VA Form FL-10-212 Fillable: Request Medical Records Guide – VA Form FL-10-212 is an official Veterans Health Administration (VHA) form used to authorize the release of your protected health information from a non-VA healthcare provider to the Department of Veterans Affairs. Although commonly referred to in the context of requesting medical records, its full title is Authorization for Release of Protected Health Information to the Department of Veterans Affairs.

This fillable PDF (last revised October 2011) helps ensure your VA care team or approved VA research protocols receive necessary records from private doctors, hospitals, or other external health entities for continuity of treatment.

What Is VA Form FL-10-212?

FL-10-212 is a VHA form letter (FL) designed specifically for situations where a VA medical facility needs your medical records from an outside (non-VA) healthcare provider.

You (the patient or authorized representative) sign the form to give permission for that provider to release specific records directly to the VA. The form includes options to request particular types of records and to authorize release of sensitive information such as mental health, substance abuse, psychotherapy notes, or HIV-related information.

Key details:

  • Form number: FL 10-212
  • Revision date: October 2011
  • Format: Fillable PDF
  • Official source: Hosted on VA.gov

Purpose of VA Form FL-10-212

The primary purpose is to support continuity of care at a VA health facility or to assist with approved VA research protocols.

By signing, you authorize the named health care entity to release:

  • Discharge summaries
  • History and physical exams
  • Laboratory information
  • Radiology reports
  • Other specified records

Any radiology films or laboratory slides are returned after review. The form also contains required statements about voluntary authorization, revocation rights, expiration, and redisclosure under HIPAA and other federal regulations.

When Should You Use VA Form FL-10-212?

Use this form when:

  • Your VA provider or medical center has asked you to complete it so they can obtain records from a private doctor, clinic, or hospital.
  • You are participating in an approved VA research study that requires outside records.
  • You need a straightforward authorization for treatment-related record sharing with your VHA facility.

Important note on current processes: For most veterans today, the fastest ways to access or request VA medical records are through the online My HealtheVet experience on VA.gov or by submitting VA Form 10-5345a. For disability claims involving private records, VA Form 21-4142 is typically the standard form used.

FL-10-212 remains a valid tool for specific VHA treatment or research needs. Always confirm the preferred method with your local VA medical center’s Release of Information (ROI) office.

How to Download the Fillable VA Form FL-10-212

Download the official fillable version directly from VA.gov:

Download VA Form FL-10-212 Fillable PDF

Open the file in a PDF reader that supports form fields (Adobe Acrobat Reader or similar is recommended). Save a copy before filling it out.

Step-by-Step Guide to Completing VA Form FL-10-212

  1. Open the fillable PDF and enable editing/filling if prompted.
  2. Complete patient identification fields (typically at the top): full name, Social Security number, date of birth, current address, and contact information.
  3. Identify the health care entity releasing the records: Enter the name and address of the private doctor, hospital, clinic, or other non-VA provider.
  4. Specify the VA destination: Use the “In Reply Refer To” section or any designated VA address field. Your VA facility may pre-fill this or provide the correct mailing/fax details.
  5. Indicate the date range of records requested (if “From to ” fields are present) or check “as specified below.”
  6. Select types of information using the checkboxes: Discharge Summary, History and physical exam, Laboratory Information, Radiology Reports, or Other (write in specifics).
  7. Authorize sensitive information (if applicable): Initial next to Substance Abuse (including alcohol/drug abuse), Mental Health, Psychotherapy Notes, and/or HIV-related information. This step is required for compliance with special federal protections.
  8. Review and certify the statements on the form. You are confirming the request is voluntary and the information is accurate.
  9. Sign and date the form as the patient or authorized representative (guardian or power of attorney). Print your name clearly and indicate your status if signing as a representative.
  10. Save the completed form and make copies for your records.

Tip: Double-check that all required fields are filled. Incomplete forms may delay processing.

Where and How to Submit the Completed Form?

  • Give the signed form to the non-VA healthcare provider (they will usually send your records along with a copy of the authorization to the VA address listed).
  • Or submit it directly to your VA medical center’s Release of Information (ROI) / Health Information Management office.
  • The form includes a note instructing the provider to send a copy of the request with the health information to the VA address shown.

Contact your specific VA facility for preferred submission methods (mail, fax, or in-person drop-off) and current processing details. You can find your local facility using the VA Facility Locator.

What Happens After You Submit?

The outside provider reviews and releases the authorized records to the VA. Processing times vary depending on the provider and volume at the VA facility—expect several weeks in many cases.

Your VA care team will be notified once records are received and added to your electronic health record. You will receive a copy of the signed authorization form.

Frequently Asked Questions About VA Form FL-10-212

Is FL-10-212 still valid in 2026?
Yes. The form remains officially hosted on VA.gov and is still used by some VHA facilities, although newer processes and forms exist for many situations.

Do I need to notarize the form?
The form does not require notarization based on the current version.

Can I use this form for a VA disability claim?
It may be accepted in some cases, but VA Form 21-4142 (Authorization to Disclose Information to the Department of Veterans Affairs) is the standard form for claims-related requests. Check with your claims processor or accredited representative.

What if I want to revoke the authorization?
You can revoke it in writing to the health care entity at any time (except to the extent action has already been taken). The authorization also expires automatically once the requested information has been supplied to VA.

Can someone else sign for me?
Yes, if they are your guardian or hold power of attorney. Clearly indicate their status on the form.

Here are trusted, current resources for veterans:

Tips for a Smooth Medical Records Request

  • Start with the online My HealtheVet portal on VA.gov whenever possible — it is often the quickest method for VA records.
  • Keep copies of everything you submit.
  • Follow up politely with both the external provider and your VA ROI office if records are delayed.
  • If you have questions about which form to use, call or visit your local VA medical center’s Release of Information office — they can provide the most current guidance for your specific situation.
  • For complex claims or appeals, consider working with an accredited Veterans Service Organization (VSO) or claims agent.

This guide is based on official VA sources and the current version of the form available on VA.gov. Forms, processes, and online tools can change, so always verify the latest information directly on va.gov or with your VA healthcare team.

Disclaimer: This article is for informational purposes only and does not constitute legal or medical advice. For personalized assistance, contact your VA medical center or visit official VA.gov resources.