Forms & Policies
Information & documentation for managing your healthcare
Review hospital policies for patients, visitors, and families. Find forms to help you address the logistics of healthcare.
Forms
Here's the main forms you need to manage your healthcare.
HIPAA Forms: Your Healthcare Privacy
We keep your medical records and health information private, complying with HIPAA. View:
Advance Directives Forms & Planning Guide
Read our guide on planning for your healthcare, should you ever need someone else to make your healthcare decisions. Learn how and why to download the advance directive form.
Start Your Healthcare Planning
Medical Records Forms
Learn how to:
- Give other people access to your medical records
- Grant access to your MyChart account
- Gain access to the records or MyChart of a child or incapacitated adult
Manage & Share Medical Records
Release of Medical Information Authorization Form: To request the release of your medical records
Authorization for UVA Health – Disclosures of Confidential Substance Use Disorder (SUD) Form: To allow UVA Health to release medical records for substance use disorder treatment
- English (PDF)
Request for Restriction on Uses & Disclosures of Health Information Form: To request we limit on who receives some or all of your health information
Request for Non-Disclosure of Health Information to Health Plan Form: To prevent the disclosure of your health information to a healthcare service that you have paid for in full
Request for Accounting of Disclosures of Health Information: Report of who and when your health information was shared
Request for Amendment of Health Information Form: To request changes or corrections in your medical record
Authorization for Sharing of Information Patient to Patient Form: To allow a provider to share your medical information with another patient
- English (PDF)
MyChart Proxy Forms
These provide the ability to access another patient’s MyChart information.
For Adult Patients (18 years of age and older)
Adult Proxy Access to MyChart by Another Adult Form: Both adults are able to legally make their own medical decisions
Caregiver Proxy Access to MyChart: Patient is unable to make their own medical decisions/lacks capacity
Minor Patients (birth to 17 years of age)
Parent/Legal Guardian Proxy Access to MyChart (Child under 13 years old) Form: Parent or legal guardian accessing Mychart for patient’s aged 13 years or less
Parent/Legal Guardian/Other Adult Proxy Access to Adolescent MyChart (Child aged 13-17 years old) Form: Parent or legal guardian requesting access to MyChart for patient’s aged 13-17 years old
Caregiver Proxy Access to MyChart Form: Patient (aged 13-17 years old) is unable to make their own medical decisions/lacks capacity
Minor Child Delegation & Hospital Education Forms
Delegation of Authority – Consent for Routine Care for a Minor Form: To give a family or trusted adult permission to bring your child for routine care and treatment
Hospital Education Program Form: To approve the Hospital Education team to access your minor child’s medical records
- English (PDF)