How to Request Your Medical Records

Instructions on requesting a copy of your medical records

To request a copy of your medical records, you will need to complete the form, Authorization for Release of Medical Information.

• Download the Authorization for Release of Medical Information (PDF) form for UVA Health System in English
• La forma de Autorizacion Para la Divulgacion de Informacion Médica (PDF) del UVA Health System en Español
  

Please read the entire authorization form and complete the following:

• Patient name, address, phones numbers and date of birth
• Information you are requesting to be released, including the UVA clinician’s name and the dates of the requested information
• Person or organization to receive your medical record information (example: Dr. John Brown). If the information is for yourself, you will need to complete this section with your name and address. List the reason for requesting the release of your medical records. If it is for your own personal use, write “For Personal Use”.
• Signature of Authorization to Release Confidential Healthcare Information
• Your signature or a legal representative’s signature
• Date of signature
• If signed by a legal representative, a description of the representative’s authority to act in your behalf

Please note the following:

The authorization will be valid for 12 months from the date of signature. UVA Health System charges for copies of health information in compliance with Virginia statutes as follows:

• Patients: $.50 per page for pages 1-50, $.25 per page for pages 51+, plus actual postage if mailed
• All other requestors: As state and federal laws allow

Submit the completed form to the following:

UVA Health System
Release of Information, Health Information Services
P.O. Box 800476, Charlottesville, VA 22908
Fax 434.243.5995

Contact Health Information Services at 434.924.5136 with any questions.

Test Results

For medical tests results, call your primary care provider or the doctor who ordered the tests.