Forms & Policies

Coming to the hospital or clinic? Find current patient & visitor policies.

Patient Rights & Policies

• Learn about your rights as a patient.
• Read our nondiscrimination policy.
• Review the website privacy policy.
• See the rules around having an animal in the hospital.
• See the rules about having your designated support person with you while getting care if you're a person with disabilities.

HIPAA: Your Privacy

We keep your medical records and health information private, complying with HIPAA. View:

• UVA Health HIPAA privacy policy in English (PDF) or HIPAA policy en Español (PDF)
• Culpeper, Haymarket, and Prince William privacy policy (PDF)

Medical Records Release Forms

Allow the sharing of your medical records and/or health information with a third party: 

• Authorization for Release of Medical Information, English (PDF)
• Autorización para Revelar Información Médica, Español (PDF)

Request limits on who receives some or all of your health information:

• Request for restriction on uses & disclosures of health information (PDF)

Prevent disclosure to your health insurance of a healthcare service that you have paid for in full:

• Request for non-disclosure of health information to health plan (PDF)

Allow a provider to share your medical information with another patient:

• Authorization for Sharing of Information: Patient to Patient (PDF)

Find out when and to whom your health information was shared:

• Request for accounting of disclosures of health information (PDF)

Ask for changes or corrections in your medical record: 

• Request for amendment of health information (PDF)

MyChart Forms: Access Requests

Request access for another adult to your MyChart account: 

• Adult Proxy Access to MyChart by Another Adult | Proxy Authorization Form (PDF)

Request caregiver access to an incapacitated adult's MyChart account: 

• Adult Proxy Access to MyChart by Caregivers | Proxy Authorization Form, English (PDF)
• Acceso de Apoderado a MyChart Para "Cuidadores", Español (PDF)

Request access to a patient's medical records for non-clinical purposes:

• Request for medical records (for non-patient care purposes) (PDF)

Access to a Child's MyChart

Request access to a child's (under age 13) MyChart account:

• Parent/Legal Guardian Proxy Access to MyChart, English (PDF)
• Acceso a Mychart como Padre o Representante Legal (Menor de 13 Años de Edad), Español (PDF)

Request access to an adolescent child's (over age 13) MyChart account:

• Parent/Legal Guardian/Other Adult Proxy Access to Adolescent MyChart, English (PDF)
• Acceso de Poderhabiente para el Padre/Tutor Legal/Otro Adulto a Mychart para Adolescentes, Español (PDF)

Give the Hospital Education Program access to your child's medical records: 

• Authorization for Access by Hospital Education (PDF)

Advance Directives

Use an advance directive to plan your future medical care and health decisions.

Choose your advance directive form options.

Clinic Late, No-Show, & Cancellation Policy

• If you’re late to your clinic appointment, and we can’t fit you in, we’ll reschedule your appointment.
• New patient? After 2 no-shows for a first appointment, we won’t reschedule you.
• Already a patient? If you have 3 no-shows in 1 year, we may dismiss you from the clinic.
• We treat 2 late cancellations the same as 1 no-show. 
• We know things happen. We don't count no-shows and late cancellations that happen for reasons outside your control. 

Definitions

• No-show: Not coming to an appointment and not calling ahead to let us know you can't make it. 
• Late cancellation: Cancelling with less than 24 hours’ notice.