Medical records forms

Below are links to a list of forms related to requesting medical records for yourself or someone who has given you written permission. These forms apply to UVA Health Culpeper Medical Center, UVA Health Haymarket Medical Center, and UVA Health Prince William Medical Center. 

• Authorization to Disclose Protected Health or Billing Information
• Autorización para divulgar información médica protegida o de facturación (Spanish)
• Patient Request for Access to Protected Health Information
• Request to Exercise Privacy Rights – Amendment of Medical Record
• Request to Exercise Privacy Rights – Restrict the Use or Disclosure of PHI
• Request to Exercise Privacy Rights – Accounting of Disclosures