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FORM # 030105 CAT: 15 - PATIENT DATA (REV. 03/11) To reorder, log onto 1 OF 1
University of Virginia Health System
Release of Information, Health Information Services
PO Box 800476, Charlottesville, VA 22908
Phone 434-924-5136 Fax 434-924-2432
_______________________________________________________________________________________________ ___________________________
(Print patient’s full name) Birth date (Mo/Day/Yr)
_______________________________________________________________________________________________ ___________________________
(Street address) Phone (Home or Cell)
_______________________________________________________________________________________________ ___________________________
(City, state, zip code) Phone (Work)
I ______________________________________, hereby authorize University of Virginia Health System, to release:
(patient or patient name)
___________ Discharge Summary [date(s)] ___________ History & Physical [date(s)] ___________ Operative Report [date(s)]
___________ Pathology Reports [date(s)] ___________ Immunization Record ___________ X-Ray and Imaging Report [date(s)]
___________ Laboratory Results [date(s)] ___________ Emergency Room Record [date(s)] ___________ Entire Record [date(s)]
___________ Consultation Report [date(s)] and Doctors Name:__________________________________________________________________________________
___________ Clinic Notes [date(s)] and Doctors Name: _________________________________________________________________________________________
___________ Other: __________________________________________________________________________________________________________________________
Pharmacy: (For Patient Assistance Program) _____ Allergy Inform _____ Diagnosis _____ Financial _____ Insurance _____ Medication
If this authorization is for release of medical records, I understand that I am giving my permission to release copies of 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
Purpose of Disclosure: _____ Personal _____ Continuing Care _____ Insurance _____ Attorney
_____ Workers Comp _____ Other/state purpose _______________________________________________________________
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 notication but that it will not affect any information released prior to notication
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 as I request, I understand there is a fee of $.50 per page for pages 1-50, $.25 per page for pages 51+,
plus actual postage if mailed. Fees are waived when copies are requested by other health care providers agencies/facilities for continuing care. All
other requestors are charged as state and federal laws allow.
________________________________________________________________________________________________ _________________________________
Signature of Patient or Legal Representative of patient Date
If signed by Legal Representative, Describe Authority to act on Patients Behalf
If Translated: INTERPRETER ATTESTATION (when applicable)
Translation has been provided by: ____________________________________________________________________________ Date/Time: __________________
Recibi una copie traducida de este documento. Patient Initials ___________
(I received a translated copy of this document) Form # _________________
Virginia Authorization For Release of Medical Information
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