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Authorization For Release of Medical Information

This document is an authorization form for the release of medical records from the University of Virginia Health System. It contains the patient's name and contact information. The patient authorizes UVA to release copies of pertinent medical records, including discharge summaries, clinic notes, imaging reports, and pharmacy records. The records can be released to the patient themselves or another specified individual or organization. The purpose and valid timeframe of the disclosure is also provided. The patient signs to authorize the release of their information as specified.

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241 views1 page

Authorization For Release of Medical Information

This document is an authorization form for the release of medical records from the University of Virginia Health System. It contains the patient's name and contact information. The patient authorizes UVA to release copies of pertinent medical records, including discharge summaries, clinic notes, imaging reports, and pharmacy records. The records can be released to the patient themselves or another specified individual or organization. The purpose and valid timeframe of the disclosure is also provided. The patient signs to authorize the release of their information as specified.

Uploaded by

cig3f
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PLACE LABEL HERE.

*1500000* 1500000 IF LABEL NOT AVAILABLE, WRITE IN PT NAME & MR#

University of Virginia – Health Information Services


PO Box 800476, Charlottesville, VA 22908
Phone 434-924-5136 Fax 434-924-2432
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
For UVA Health Information Services Release Purposes Only

(Patient’s full name or Legal Guardian) Birth date (Mo/Day/Yr.)

(Street address) Phone (Home or Cell)

(City, state, zip code) Phone (Work)

Fees are waived when copies are requested by other health care provider’s agencies/facilities for continuing care or by patients. All other
requestors are charged as state and federal laws allow. Photo ID is required.

I , hereby authorize University of Virginia Health System, to release:


(patient, legal guardian)

COPIES OF MEDICAL RECORDS:


☐ PERTINENT ELEMENTS ONLY (MOST RECENT DISCHARGE SUMMARY, HISTORY & PHYSICAL, AND OPERATIVE RECORD)
☐ OTHER ELEMENTS
☐ Immunization Record ☐ X-Ray and Imaging Report [date(s)]
☐ Clinic Notes [date(s)] and Doctors Name ☐ X-Ray/Imaging Film/CD [date(s)] _
☐ Other: ☐ To include Dental Imaging [date(s)]
☐ Emergency Room Record [date(s)]

☐ Pharmacy: (For Patient Assistance Program) ☐ Allergy Inform ☐Diagnosis ☐ Financial ☐ Insurance ☐ Medication

MEDIA TYPE:
 MyChart  CD  Paper

I understand that I am giving my permission to release information in my medical record that may include information relating to psychiatric
treatment, drug/alcohol treatment, AIDS/HIV testing or treatment of sexually transmitted disease, unless indicated in the following instructions:

INFORMATION RELEASE TO:


NAME (Physician, hospital, agency, etc.)

Street address

City, state, zip

☐ Self (information noted above)

Purpose of Disclosure:  Personal  Insurance  Attorney  Workers Comp

I hereby authorize disclosure of the health information for the above named patient. This authorization is valid for 12 months from the date of signature.
I understand that I may cancel this request with written notification but that it will not affect any information released prior to notification of cancellation.
I understand that the information disclosed may be subject to re-disclosure by the person or facility receiving it, and would then no longer be protected
by federal regulations. I understand that the University of Virginia Health System may not condition its providing of health care on whether copies to
individuals or organizations are released as I request.

Signature of Patient or Legal Representative of Patient Date

If I am not the patient and am signing as the patient’s legal (authorized) representative, I attest that the patient lacks capacity to make
the decision to release the medical records as specified above.

Patient’s Authorized Representative Date

CLINICAL FORM# 030105 REV. 09/2019 1 OF 1

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