VA Form 10-0539 PDF Details

The VA Form 10-0539, integral to the administration of medical and supportive roles within the Department of Veterans Affairs (VA), delineates the assignment of functional categories for employees, underscoring the governance of access or non-access to Protected Health Information (PHI). Tailored primarily for Medical Residents/Fellows, the form meticulously outlines the procedures for determining the level of information accessibility based on the employee's role, ranging from direct care providers with entire medical record access for treatment purposes to non-health roles like the Veterans Canteen Service with no need for PHI access. It acts as a compliance tool to ensure that information access is strictly aligned with the operational needs and privacy regulations. By categorizing employees and specifying allowable systems of records, it provides a structured approach to PHI access, thereby preventing unauthorized viewing or handling. Supervisors play a crucial role, tasked with reviewing, obtaining signatures, and maintaining these records, ensuring that access rights are appropriately assigned and documented, further emphasizing the VA's commitment to safeguarding veterans' health information while facilitating care and administrative functions. The form's significance extends beyond mere documentation; it embodies a conscious effort to balance the need for information in providing care and support with the imperative of preserving confidentiality and privacy.

QuestionAnswer
Form NameVA Form 10-0539
Form Length2 pages
Fillable?Yes
Fillable fields1
Avg. time to fill out42 sec
Other namesva form 10 0539 fillable, assignment of functional categories form oct 2018, va form 10 0359, va 10 539

Form Preview Example

Assignment of Functional Categories

Employee's Name:

Job Title: Medical Resident/Fellow

Department/Service Assigned:

If employee falls into more than one functional category listed below, access should be granted based on the less restrictive category to meet the need of an intended purpose.

This table shows access or non access to PHI in regards to functional category, it does not show if a user needs access to their own System of Records in order to complete their job functions.

Immediate Supervisor: Check off functional category, review with employee, obtain signatures, and maintain copy in the Supervisor's Personnel Files (RCS 10-1, 05-3) for the individual employee.

Access or use of Protected Health Information (PHI) not required (EMS, Veterans Canteen Service, Mailroom Employee, etc.)

 

 

 

Functional Categories

Type of Protected Health

Allowable Systems

 

 

 

 

of Records for

Conditions for Access to Information

 

 

 

(Class of Persons)

Information Accessible

 

 

 

Limited Access

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Direct Care Providers

Entire Medical Record

 

Treatment of Individuals

 

 

 

 

 

 

 

 

 

 

 

 

 

Department of Veterans

Entire Medical Record

 

Activities as approved by an Institutional

 

 

 

 

Review Board or Privacy Board;

 

 

 

 

 

 

Affairs (VA) Researchers

including research records

 

 

 

 

 

reparatory to research

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Indirect Care Providers

Entire Medical Record

 

In support of treatment of individuals

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Business Office

Entire Medical Record

 

In support of payment of Individuals care

 

 

 

 

 

 

Administrative

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Information Support

 

 

Assign diagnostic codes to transcribe, file,

 

 

 

Entire Medical Record

 

release information, and provide or

 

 

 

 

 

 

Services

 

 

 

 

 

 

input registry data

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Inspections, investigations,

 

 

 

Quality, Oversight and

Entire Medical Record

 

complaint review and resolution, quality

 

 

 

 

 

 

Investigations

including research records

 

reviews and compliance, congressional

 

 

 

 

 

 

 

 

 

response

 

 

 

 

 

 

 

 

 

 

Mail Room

No Need for access to PHI

 

Mail Room Staff

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chief of Police

Limited Health Record

79VA19, 24VA19

Chief of Police looking up patients

 

 

 

 

 

 

information in Patient Inquiry

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Police and Security Service

No Need for access to PHI

 

Security Police, and Police Staff

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient safety, radiation safety,

 

 

 

Safety

No Need for access to PHI

 

environmental safety and biomedical

 

 

 

 

 

 

 

 

 

 

safety

 

 

 

 

 

 

 

 

 

 

Information Security, Privacy,

Entire Health Record

 

Monitoring and tracking of security

 

 

 

Compliance, VISN Staff,

 

 

 

 

including research records

 

privacy and compliance issues

 

 

 

Patient Advocate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contracting, Human Resources,

 

 

 

Operations Support and

No need for access to PHI

 

Acquisitions, Environmental, Engineering,

 

 

 

 

 

 

Environmental Services

 

Employee Education Service, Forms,

 

 

 

 

 

 

 

 

 

 

 

Publications, and Library

 

 

 

 

 

 

 

VA FORM

 

 

 

 

JAN 2012 10-0539

 

 

 

 

 

 

Functional Categories

Type of Protected Health

Allowable Systems

 

 

 

 

of Records for

Conditions for Access to Information

 

 

 

(Class of Persons)

Information Accessible

 

 

 

Limited Access

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24VA19, 79VA19,

 

 

 

 

 

Limited access, where

121VA19 and any

Operation and management,

 

 

 

Leadership and Management

necessary to complete

other system of

executive decisions for health care

 

 

 

 

 

 

assignment

records with national

operations

 

 

 

 

 

data.

 

 

 

 

 

 

 

 

 

 

 

Non Health Information

Limited Health Record, where

 

Administrative Support, medical media,

 

 

 

necessary to complete

79VA19

public affairs, mail room,

 

 

 

 

 

Administrative Support

 

 

 

assignment

 

telecommunications, and information desk

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eligibility and Enrollment Staff

Entire Health Record

 

For enrollment, eligibility, income and

 

 

 

 

 

 

 

 

insurance verification

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

79VA19, 24VA19,

 

 

 

 

 

Limited Health Record,

121VA19 and any

Computer Systems Maintenance and

 

 

 

Information Technology

where necessary to complete

other system of

 

 

 

 

 

 

Support

 

 

 

 

assignment

records for an IT

 

 

 

 

 

 

 

 

 

 

system.

 

 

 

 

 

 

 

 

 

 

 

Veterans Canteen Service

No need for access to PHI

 

Cafeteria, Retail Store

 

 

 

 

 

 

 

 

 

 

 

 

 

Volunteer Services

Limited Health Record

79VA19, 24VA19

Transportation and other services

 

 

 

 

 

 

 

 

 

By signing this document I acknowledge and understand that I have been assigned the functional categories listed above and given computer access and VistA menu options to access and use Protected Health Information only in the performance of my official job duties and assigned task.

Employee's Signature:

 

Date:

 

 

 

Supervisor's Signature:

 

Date:

 

 

 

Interim Review for Position Change

Interim Review for Job Assignment Change

 

 

 

The following changes have been made to employees' functional category:

No changes made, functional category and menu options to remain the same

Employee's Signature:

Date:

Supervisor's Signature:

Date:

VA FORM

JAN 2012 10-0539

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Step no. 1 in filling in electronic va form 10 0539

2. When this section is done, you're ready insert the essential details in Indirect Care Providers, Entire Medical Record, In support of treatment of, Business Office Administrative, Entire Medical Record, In support of payment of, Health Information Support Services, Entire Medical Record, Quality Oversight and, Entire Medical Record including, Assign diagnostic codes to, Medical Inspections investigations, Mail Room, No Need for access to PHI, and Mail Room Staff so you're able to proceed to the third stage.

electronic va form 10 0539 conclusion process described (part 2)

3. This third part is generally hassle-free - complete all the form fields in Operations Support and, No need for access to PHI, VA FORM, JAN, and Contracting Human Resources in order to complete this process.

Find out how to complete electronic va form 10 0539 portion 3

4. To go forward, this next stage requires completing a couple of blank fields. Examples of these are Leadership and Management, Limited access where necessary to, VA VA VA and any other system of, Operation and management executive, Non Health Information, Limited Health Record where, Administrative Support medical, Eligibility and Enrollment Staff, Information Technology, Limited Health Record where, VA VA VA and any other system of, For enrollment eligibility income, Computer Systems Maintenance and, Veterans Canteen Service, and No need for access to PHI, which are integral to continuing with this document.

Filling in part 4 in electronic va form 10 0539

People frequently make mistakes while completing Limited Health Record where in this part. Remember to re-examine what you enter right here.

5. Finally, the following final subsection is what you have to finish before closing the PDF. The fields at issue include the following: By signing this document I, Employees Signature, Supervisors Signature, Date, Date, Interim Review for Position Change, Interim Review for Job Assignment, The following changes have been, No changes made functional, Employees Signature, Supervisors Signature, Date, and Date.

electronic va form 10 0539 completion process shown (part 5)

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