Authorization For Release Of Medical Record Information (Page 2 of 2) in pdf

Virginia Hospital Center’s

INSTRUCTIONS FOR COMPLETING

AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION

To insure the timely processing of your request, please fill out

entire form, lines 1-16. VHC will not be able to process your

request without it.

Items 1-4:

Name should be the name of the patient at the time of treatment.

Item 5:

Please check one box for the “Purpose” of the request.

Please check one box for the “Means” of the request.

If means of delivery is “Fax”, Virginia Hospital Center only faxes directly to

medical facilities/offices and only if records would not reach facility/office by mail in time for

any appointment indicated at the top of the authorization. Please provide both the fax number

and phone number of the medical facility/office at top of page. You will then need to complete

Item 6 with the doctor’s name and address.

*PLEASE NOTE: If means of delivery is “Pick Up”, you will receive a phone call when record copies are ready.

You will then have 5 business days to pick up record copies. After the 5

business day, record copies are

destroyed. A bill will be automatically generated whether or not record copies are picked up. If you fail to pick up

record copies after the first request, any additional requests will incur additional charges.

Item 6:

*DO NOT FILL IN WITH “SELF” OR “SEE ABOVE”. MUST FILL IN COMPLETELY.

This information MUST be provided. Write the name and full address of person you want to

receive the copies, even if they are being sent to yourself.

*PLEASE NOTE: Person identified in this line will be billed.*

Item 7:

You need to indicate specific dates OR a range of dates covering the dates of the visit. If it was a

one-day visit, repeat the same date after date “to” as you indicated after date “from”.

Item 8:

HIPAA guidelines limit Virginia Hospital Center to release “minimum necessary” to medical

facilities. Our policy is to limit faxes to 10 pages, including Discharge Summary, History and

Physical, Labs, Radiology (“Xray…”), EKG’s and Operative Reports/Pathology. If the visit was

ER only, the Emergency Room Record will be sent in full, unless only specific parts are

indicated on your request. The physician may make a direct or subsequent request for other

reports needed for continuing care. Again, we only fax records to physicians and other

hospitals.

You as the patient, may request a copy of your records for your own personal use

You must complete an Authorization for Release of Medical Record Information form.

Please note that there is a copy fee for a copy of your record. The fee is as follows:

$. 50 per page up to 50 pages, $ .25 per page 51+ pages, $1.00 per page for copies made

from microfiche, and postage. Our processing time is 15 days.

Items 9-13

The space on Item 11 may be left blank if you agree to an expiration timeframe of 1 year. If you

wish the timeframe to be shorter, you may indicate a specific date or timeframe.

Items 14-16

Please enter the date that you are signing and your signature. If you have POA or you are the

administrator for a deceased patient, we will need additional documentation. Please call us

for details.

If you have any questions, please call the Health Information Management department at

(703) 558-2403.

Authorization For Release Of Medical Record Information Page 2

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