Form FL 10-212, Request for Medical Records, is the authorization the Veterans Health Administration (VHA), part of the U.S. Department of Veterans Affairs, uses to obtain a patient's health information from another health care entity. The patient, or an authorized representative, signs it to allow that entity to release the records to VA. On FillingPDF you can fill out the form online and download or print the completed PDF; the official PDF is published by VA at va.gov.
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What is FL 10-212?
Form FL 10-212, Request for Medical Records, is a Department of Veterans Affairs (VA) form in which a patient authorizes a named health care entity to release protected health information to VA, so that VHA staff can use it for treatment or an approved research protocol.
The form states two purposes for the disclosure: to help Veterans Health Administration (VHA) clinical staff with the patient's continuity of treatment, or to help VHA investigators conduct an approved VA research protocol in which the patient is a subject. Any radiology films or laboratory slides sent are returned after review.
The patient chooses what is released. The form provides a date range ("From ... to ...") or a description under "as specified below", and boxes for Discharge Summary, History and physical exam, Laboratory Information, Radiology Reports and Other. Four sensitive categories are released only if the patient places initials next to them: substance abuse (including alcohol and drug abuse), mental health, psychotherapy notes, and HIV-related information, including HIV-related testing.
The form also lists the patient's rights. The health care entity may not condition treatment, payment, enrollment or eligibility for benefits on the patient signing. The patient may revoke the authorization in writing to the health care entity at any time, except to the extent that action has already been taken to comply with it. The consent expires automatically after the requested information has been supplied to VA, and the patient receives a copy of the signed form.
Who needs to file FL 10-212?
The main group is a patient whose health information is held by a health care entity outside VA and whom VHA clinical staff need that information for, in order to continue treatment. The form also serves a patient who is a subject of an approved VA research protocol when VHA investigators need the records.
The patient signs the form. An authorized representative may sign instead: the signature block has a line for the Signature of Patient or Authorized Representative and a line to print the patient name or the authorized representative's name, with the representative's status shown as Guardian/POA.
The form does not apply to anyone who does not want the listed categories of information released. Only the items checked and, for the four sensitive categories, the items initialed are authorized. The form also says the health care entity may not make treatment, payment, enrollment or eligibility for benefits depend on signing, so signing is a free choice.
When to file FL 10-212
Use Form FL 10-212 when VHA needs your records from another health care entity, either for continuity of your treatment or for an approved VA research protocol in which you are a subject. The form prints no filing deadline.
The authorization has no fixed term. Without an express revocation, the consent expires automatically after the requested information has been supplied to VA. You may revoke it earlier, in writing, to the health care entity at any time, except to the extent that the entity has already acted on it.
The date range on the form ("From ... to ...") limits which records are covered, so complete it according to the period VHA needs.
How to fill out FL 10-212
Check the entity and VA address
Confirm that the health care entity you authorize is named on the form and that the VA address at the top of the page is the one where the records should be sent.
Set the date range
Under "Information to be released", enter the beginning and end dates in the "From ... to" fields, or describe the period under "as specified below".
Check the types of information
Mark each item you want released: Discharge Summary, History and physical exam, Laboratory Information, Radiology Reports, or Other, describing it if you choose Other.
Initial sensitive categories you authorize
Place your initials next to Substance Abuse, Mental Health, Psychotherapy Notes or HIV related information only for the categories you specifically authorize to be released.
Read the certification and rights
Read the statements on voluntary consent, no conditioning of treatment, revocation, automatic expiration and redisclosure before you sign.
Sign and date the form
Sign on the Signature of Patient or Authorized Representative line and enter the date. Print the patient name, or the authorized representative's name, on the line below.
Show the representative's status
If someone signs for the patient, enter the representative's status, such as Guardian/POA, in the status line.
Review and download the completed PDF
Check the date range, checked boxes, initials, signature and date, then download or print the completed PDF from FillingPDF and keep the copy you receive.
How to submit FL 10-212
The form prints no online portal or fax number. Its closing note describes how the records reach VA: the health care entity is asked to send a copy of the request, together with the health information requested, to the VA address printed at the top of the form.
- Give the signed form to the health care entity named on it. The authorization is addressed to that entity, which releases the records.
- Records go to the VA address on the form. The note on the form asks that a copy of this request accompany the health information sent to the VA address above.
- Revocation. If you later withdraw the authorization, do it in writing to the health care entity, not to VA.
You receive a copy of the form after you sign it. Keep it for your records. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Leaving out your initials next to Substance Abuse, Mental Health, Psychotherapy Notes or HIV related information when you want that information released; the form authorizes these only if you initial them.
- Signing without printing the patient name or authorized representative's name, or leaving the date blank next to the signature.
- Signing as an authorized representative without showing your status (Guardian/POA) in the status line.
- Leaving the date range and the information boxes unmarked, so it is unclear which records you authorize.
- Sending health information to VA without a copy of this request; the form's note asks that a copy accompany the records.
- Sending a revocation to VA instead of to the health care entity; the form says revocation is made in writing to the health care entity.
- Treating signing as a condition of care; the form states the entity may not condition treatment, payment, enrollment or eligibility for benefits on your signature.
Frequently asked questions
What is Form FL 10-212, Request for Medical Records?
It is a VA authorization on which a patient allows a named health care entity to release protected health information to the Department of Veterans Affairs. VHA uses the records for continuity of treatment or for an approved VA research protocol in which the patient is a subject.
Do I have to initial anything on the request for medical records?
Only if you want the sensitive categories released. The form releases Substance Abuse, Mental Health, Psychotherapy Notes and HIV related information only when you place your initials next to the specific condition. Without initials, those items are not authorized.
Can someone sign Form FL 10-212 for me?
Yes. The signature line reads Signature of Patient or Authorized Representative, and the form has a status line for the representative, shown as Guardian/POA. Print the name of the patient or the authorized representative on the line provided.
Can the health care entity refuse care if I do not sign?
No. The form states that the health care entity may not condition treatment, payment, enrollment or eligibility for benefits on your signing the authorization. Signing is voluntary, and the form certifies it was made freely and without coercion.
How long does the authorization last, and can I cancel it?
Without an express revocation, it expires automatically after the requested information has been supplied to VA. You may revoke it at any time in writing to the health care entity, except to the extent action has already been taken to comply with it.
Where do the records go after I sign?
To the VA address printed at the top of the form. The note at the end asks that a copy of the request accompany the health information sent there. The form lists no online portal or fax number.
Can I fill out Form FL 10-212 online?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not send the form to VA or to your health care entity; delivery follows the channels on the form.
Is my information still protected after it is released to VA?
The form warns that those who receive the information may redisclose it without your further written authorization, and that it may no longer be protected by federal laws or regulation. Read this statement before signing.
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