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Link to form
https://www.va.gov/vaforms/medical/pdf/vha-10-0525a-fill.pdf
Form number
10-0525a
Row ID
5334
Form title
RESTRICTION OF THE RELEASE OF INDIVIDUALLY-IDENTIFIABLE HEALTH INFORMATION THROUGH eHEALTH EXCHANGE
Issue date
Revision date
Form administration
VHA
Number of pages
2
Deleted
False
Form name
Restriction of the Release of Individually-Identifiable Health Information Through eHEALTH Exchange