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.

Culpeper Medical Center

• Authorization to Disclose Protected Health or Billing Information
• Autorización para divulgar información médica protegida o de facturación (Spanish)

Haymarket and Prince William Medical Centers

• Authorization to Disclose Protected Health or Billing Information
• Autorización para divulgar información médica protegida o de facturación (Spanish)
• Instructions for Completing the Authorization to Disclose Health or Billing Information Form
• 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