Free Medical Release Form 19Free Medical Release Form 19
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PLACE LABEL HERE

F LABEL NOT AVAILABLE, WRITE IN PT NAME & MR#

UNIVERSITY OF VIRGINIA HEALTH SYSTEM

FORM # 030105 CAT: 15 - PATIENT DATA (REV. 03/11) To reorder, log onto http://www.virginia.edu/uvaprint 1 OF 1

1500000

University of Virginia Health System
Release of Information, Health Information Services
PO Box 800476, Charlottesville, VA 22908
Phone 434-924-5136 Fax 434-924-2432

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
____________________________________________________________________________ ___________________________
(Print patient’s full name) Birth date (Mo/Day/Yr)
____________________________________________________________________________ ___________________________
(Street address) Phone (Home or Cell)

____________________________________________________________________________________
(City, state, zip code) Phone (Work)

I ______________________________________, hereby authorize University of Virginia Health System, to release:
(patient or patient name)
__