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.
• Review the terms and conditions for receiving texts about your medical care.
• See the rules about having your designated support person with you while getting care as 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)

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)

Allow UVA Health to disclose a substance abuse disorder

• Authorization for UVA Health - Disclosure of Confidential Substance Use Disorder (SUD) (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)

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)

Delegation of Authority

Use a Delegation of Authority to give another family member or trusted adult permission to bring a minor for routine care and treatment.

• Delegation of Authority - Consent for Routine Care for a Minor (PDF)
• Delegación de Autoridad - Consentir Tratamiento Rutinario para un Menor (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

See information about our late, no-show, and cancellation policy on our appointments page.