How to Fill Out and Submit the UVA Medical Records Request Form

To request your records from UVA Health, complete the UVA medical records request form — officially the Authorization for UVA Health Information Management, Release of Medical Information — and send it to the Health Information Management (HIM) department by mail, fax, or email. If you have a MyChart account and only need electronic access or want records sent to another provider, you can skip the paper form and use the portal instead.¹

Where to Get the Form

Download the PDF from the UVA Health medical records page, or pick up a paper copy at the HIM department in Charlottesville.¹ Substance use disorder treatment records use a different form, covered below.

What to Fill In

The form does three things: it identifies you, tells HIM which records to pull, and says where to send them. You’ll need to provide:²

Your full legal name, date of birth, address, and phone number. Include maiden names or prior legal names if you had care under them.
The purpose of the release: personal use, continuation of care, insurance, legal matter, or other.
Who should receive the records — you, another provider, an insurer — with their mailing address, fax, or email.
Your preferred format: MyChart, CD, or paper.
The date range of the records you want. A narrower range helps HIM find your files faster and keeps copying costs down.
The type of records: clinic notes, lab results, imaging reports, operative notes, or other specific categories.
Your signature and the date.

The authorization is valid for 12 months from the date you sign it unless you write in an earlier expiration date. If someone else is signing on your behalf, UVA requires proof of legal authority — a power of attorney, a guardianship order, or a similar court document.

Substance Use Disorder Records Use a Separate Form

Federal rules under 42 CFR Part 2 give substance use disorder treatment records stricter protection than general medical records.³ UVA uses a dedicated form for these — the Authorization for Release of Medical Information: Disclosure of Confidential Substance Use Disorder Records. It asks you to identify the UVA location that provided treatment and to check the specific categories you want released, such as assessment and diagnosis, treatment plan goals, drug screen results, or program participation notes. The standard authorization does not reach these records, so you’ll need the separate form even if you already sent in the general one.

How to Submit the Form

Send the signed form to HIM through any of these channels:¹

Mail: PO Box 800476, Charlottesville, VA 22908-0476
Fax: 434-924-2432
Email: CLHIMDCT@hscmail.mcc.virginia.edu

Fax and email start the clock sooner than mail. Include a daytime phone number so HIM can call if a field is unclear; a quick clarification can save weeks compared to having the form sent back.

MyChart Is Usually Faster

If you have a MyChart account, log in, open the menu, and go to the Sharing Hub. From there you can view records, download them, or authorize UVA to send them directly to another provider or institution.⁴ UVA calls this the easiest and fastest method.¹ Use the paper form when the records you need aren’t in the portal, when you want physical copies, or when you’re requesting records for someone else.

Fees

UVA waives fees when the records are for continuation of care or when the patient is the one requesting them. Attorneys, insurers, and other third parties can be charged up to the caps set by Virginia law.²

For paper copies, the maximum is $0.50 per page for the first 50 pages and $0.25 per page after that, plus a search and handling fee of up to $20 and actual postage. Microfilm reproductions can run up to $1.00 per page. Electronic copies are cheaper: $0.37 per page for the first 50 pages, $0.18 per page after that, with the same $20 search and handling ceiling. Total charges for an electronic request cannot exceed $160. Imaging studies have their own cap of up to $25 per X-ray series or imaging study produced electronically, plus a $10 search and handling fee.⁵ If you’re paying, electronic format keeps costs lowest.

How Long It Takes

Virginia law gives providers 30 days to furnish requested records. If UVA can’t meet that deadline, it must send you written notice with the reason, and then has no more than 30 additional days to deliver.⁵ HIPAA sets a similar 30-day window, extendable once by 30 days with written notice.⁶ If fees apply, expect an invoice before records ship.

Requesting Records for Someone Who Has Died

An executor or administrator can request a deceased patient’s records by submitting the standard authorization form along with letters testamentary or letters of administration from the court and a copy of the death certificate. If no executor or administrator has been appointed, Virginia law allows disclosure to close family in a set order of priority: spouse, then adult children, parents, adult siblings, and other blood relatives.⁷ Bring proof of the relationship — a marriage certificate, birth certificate, or similar document — along with the death certificate.

A power of attorney will not work for a deceased patient. POA authority ends at the moment of death, so even if you held it during your relative’s lifetime, you’ll need to show authority through the estate appointment or the family priority list above.

Fixing an Error in Your Records

If you spot a mistake — a wrong medication, an incorrect diagnosis code, a misspelled name — you can ask UVA to amend the record using the Request for Amendment of Health Information form, on the same page as the release authorization.¹ Under HIPAA, UVA has 60 days to act on the request, extendable once by up to 30 days with written notice.⁸ Amendments don’t erase the original entry; UVA appends the correction so future providers see both versions.

1
UVA Health. Medical Records & Health Information
2
UVA Health. Authorization for UVA Health Information Management – Release of Medical Information
3
eCFR. Confidentiality of Substance Use Disorder Patient Records
4
UVA Health. MyChart: Online Medical Records Tool
5
Virginia Code Commission. Virginia Code 8.01-413 – Certain Copies of Health Care Provider’s Health Records
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Assistant Secretary for Technology Policy. Your Health Information Rights
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Virginia Code Commission. Virginia Code 32.1-127.1:03 – Health Records Privacy
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eCFR. 45 CFR 164.526 – Amendment of Protected Health Information