PDF
Word
This version of the form is not currently in use and is provided for reference only. Download this version of
VA Form 10-0484
for the current year.
VA Form 10-0484 Revocation for Release of Individually-Identifiable Health Information
What Is VA Form 10-0484?
This is a legal form that was released by the U.S. Department of Veterans Affairs on January 1, 2011 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is VA Form 10-0484?
A: VA Form 10-0484 is a document used for the revocation of release of individually-identifiable health information.
Q: What is the purpose of VA Form 10-0484?
A: The purpose of VA Form 10-0484 is to revoke the previous consent given for the release of individually-identifiable health information.
Q: How do I use VA Form 10-0484?
A: To use VA Form 10-0484, you need to fill out the required information and submit it to the appropriate VA facility or healthcare provider.
Q: Is there a fee for submitting VA Form 10-0484?
A: There is no fee for submitting VA Form 10-0484.
Q: What happens after I submit VA Form 10-0484?
A: After you submit VA Form 10-0484, the previous consent for release of individually-identifiable health information will be revoked.
Q: How long does it take for the revocation to take effect?
A: The revocation of release of individually-identifiable health information takes effect immediately upon submission of VA Form 10-0484.
Q: Can I change my mind after submitting VA Form 10-0484?
A: Yes, you can change your mind after submitting VA Form 10-0484 by submitting a new consent form.
Q: Who can help me with VA Form 10-0484?
A: You can seek assistance from VA healthcare providers or staff at VA facilities for any questions or assistance with VA Form 10-0484.
Q: Is VA Form 10-0484 only for veterans?
A: No, VA Form 10-0484 can be used by any individual who wants to revoke the release of individually-identifiable health information through the Veterans Health Administration.
Form Details:
- Released on January 1, 2011;
- The latest available edition released by the U.S. Department of Veterans Affairs;
- Easy to use and ready to print;
- Yours to fill out and keep for your records;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of VA Form 10-0484 by clicking the link below or browse more documents and templates provided by the U.S. Department of Veterans Affairs.
