Consent For The Release Of Medical Information (Page 2 of 2) in pdf

UNIVERSITY OF VIRGINIA

DEPARTMENT OF STUDENT HEALTH

Processed:

Date:

P.O.BOX 800760

Telephone: 434-924-1525

Office Use Only

Charlottesville, VA 22908-0760

FAX

: 434-982-4262

CONSENT FOR THE RELEASE OF MEDICAL INFORMATION

Instructions: The patient must complete this form in its entirety in order for any healthcare facility to release medical

information. The patient must be specific as to the nature of the information he/she would like released and the purpose

for which it is requested.

I hereby authorize

(Name of individual or agency)

(Address)

to release my medical records as described below: (check appropriate box(s))

 General Medicine Clinic Notes & Labs

 Gynecology Clinic Notes & Labs

 CAPS Clinic Notes

 LNEC Confirmation of Disability Accommodations  Immunization Record

 Other (must specify)

accumulated during the period beginning ___________________________ and ending ___________________________

(mo/day/year)

(Name of individual or agency)

(Address)

fax

telephone

for the purpose of

This information is for use by the recipient named above only, and may not be disclosed to any other individual or agency

without the patient’s consent or as otherwise provided by law. This authorization is subject to revocation at any time

except to the extent the healthcare facility has already taken action in reliance on it.

I understand that the information in my medical records may include information related to sexually transmitted disease,

AIDS/HIV testing or diagnosis, mental health services, or drug/alcohol abuse diagnosis or treatment, and I consent to its

release unless indicated in the following instructions:

I understand that Student Health will not withhold health care if I do not sign this consent, but that disclosure of private

information to an outside entity such as a future employer or consulting physician will not be made without your consent.

A copy of this consent and a notation concerning the persons or agencies to which disclosure was made will be included

in my medical records. I understand that health information disclosed under this consent might be redisclosed by a

recipient and no longer be protected by privacy laws.

Patient’s Signature ___________________________________________ Patient’s Date of Birth

Printed Name _______________________________________________ I.D..#

Address

Telephone Number

Date: ________________________________ This authorization will expire in one year.

Revised September 17, 2007 JAM

Consent For The Release Of Medical Information Page 2

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