At Speedy Template, You can download Virginia Medical Records Release Form 3 . There are a few ways to find the forms or templates you need. You can choose forms in your state, use search feature to find the related forms. At the end of each page, there is "Download" button for the forms you are looking form if the forms don't display properly on the page, the Word or Excel or PDF files should give you a better reivew of the page.
This form is provided by University of Virginia Health System to authorize the disclosure or release of one person's protected health information.
PLACE LABEL HERE.
IF LABEL NOT AVAILABLE, WRITE IN PT NAME & MR#
UNIVERSITY OF VIRGINIA HEALTH SYSTEM
FORM # 030105 CAT: 15 - PATIENT DATA (REV. 03/11) To reorder, log onto http://www.virginia.edu/uvaprint1 OF 1
1500000
University of Virginia Health System
Release of Information, Health Information Services
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 notication but that it will not affect any information released prior to notication
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.