Authorization For Release Of Medical Record Information


Health Information Management Department
Medical Record Number
1701 North George Mason Drive
Date/Time Doctor’s Appointment
Arlington, VA 22205
Doctor’s Phone/Fax Number
Phone: 703-558-6116
FAX: 703-558-6979
Patient’s Name at Time of Treatment
Date of Birth
Street Address
Home Phone Number
Zip Code
Work / Cell Phone
(5) The undersigned hereby authorizes and requests Virginia Hospital Center to provide access to my medical record for the purpose of:
Continued Medical Care
Provide records by means of:
Fax* - Records will only be faxed for immediate direct patient care to
physician offices, hospitals, or other treatment facilities. (Patient is in office/facility receiving treatment) Items listed in # 9 and #10
**Charges may apply for record copies**
will not be faxed.
Identity of Person or Organization to send your records to. Fill in completely even if records are returning to you.
Street Address
Zip Code
The foregoing is subject to such limitations as indicated below:
(7) Covering records for the period from: (Date)________________________ to (Date)
. Date range is acceptable.
(8) Confined to the following specified information: Please check what information is needed.
Discharge Summary Reports
Outpatient/Clinic Record
Physician’s Orders
EKG Findings
Operative Reports and
(all dictated reports/
Emergency Room Record
Pathology Reports
X-ray, MRI, Ultrasound,
Progress Notes
Lab Report
and/or CT scan Reports
History and Physical Report
**Fee for copies are $.50/page up to 50 pages + $.25/page starting with 51
**Nursing notes available upon request with fees applied~
VHC has contracted with HEALTHPORT Copy Service, (GA), to process release of record copies and billing for copies of medical records.
HEALTHPORT questions? Please call 1-800-464-0035.
I hereby consent to the release of any and all records for the treatment of alcohol or drug use.
(10) I hereby authorize Virginia Hospital Center to release to the above named source the following information for the period(s) identified above:
All medical records or other information regarding my treatment, including treatment or evaluation for psychiatric and/or HIV/AIDS conditions.
(11) I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in
writing and present my written revocation to the Health Information Management Department. I understand that the revocation will not
apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to
my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked,
this authorization will expire on the following date, event, or condition: __________________________________________. If I fail to
specify an expiration date, event, or condition this authorization will expire 1 year from the date signed.
(12) I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign
this form in order to assure treatment. I understand that I may inspect the information to be used or disclosed, as provided in 45 CFR
164.524. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information
may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the HIM
Director/Privacy Officer at 703-558-6972. Virginia Hospital Center is not responsible for any re-disclosure of the information provided.
(13) I understand that there may be a charge for searching, handling, maintaining, reviewing, and preparing copies in accordance with 8.01-413
of the Code of Virginia.
(15) _____________________________________ /_____________________________________
Signature of Patient
Printed Name of Patient
(16) ___________________________________ /___________________________________
Signature of Legal Representative
Printed Legal Representative
Patient Label
Authorization for
Release of Medical
Record Information


00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Page of 2