Virginia Authorization For Release of Medical Information
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U N I V ER SIT Y OF V IRGIN I A HE A LT H SYST EM

PLACE LABEL HERE.

1500000

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

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: