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Consent For The Release Of Medical Information

To:

University of Virginia Students and Alumni

Subject: Release of Medical Records

1. You must complete a Student Health “Consent for the Release of Medical

Information Form.” You can obtain one of these forms at Student Health.

2. Occasionally Student Health receives a signed statement from a student stating that he

wishes his medical information to be released to his parents. Student Health requires

students to use a standard consent form that complies with state and federal laws for

release of medical information. If you complete the

Student Health Consent form

and

return it to us, we will be happy to respond to requests from you or your parents to

provide them the applicable medical information contained in Student Health records at

the time the request is made.

3. Options:

a. Copy of Pre-Entrance Immunization Health Form (including any immunizations

on file). No Cost

b. Copies of Medical Records are free of charge if a Student Health provider refers a

student to an outside health care provider. If a student requests copies of their

Medical Record for other reasons, the cost is $.50 per page for the first 50 pages

then $.25 per page thereafter.

4. You may review your records by obtaining a copy as noted above; or as a full time

enrolled student, you can review your records by making an appointment with a Student

Health Care Provider.

5. Student Health will respond to all routine requests for medical information within TEN

(10) WORKING DAYS after receiving a completed “Consent for the Release of Medical

Information Form.”

6. Student Health saves medical records for ten (10) years after the date of your last visit to

Student Health.

7. If you have never been seen by a Student Health care provider while enrolled in UVa,

your immunization records are kept for two (2) years after your departure from this

university.

Consent For The Release Of Medical Information