Submit this form to the Student Health and Wellness Office either through fax at 434-982-4262 or in person at the provided address. Make sure to include all necessary details to avoid delays in processing. For queries, contact them at 434-924-1525.

Important dates for submitting this form include deadlines for health service requests and renewals of authorization. Keep track of your submission dates to ensure timely processing of your medical records. Check with the Student Health for any updates on deadline specifics.

The purpose of this form is to provide patients with the ability to authorize the release of their medical information. It ensures that health records can be shared with necessary parties for continuity of care. Understanding the implications of this release is vital for protecting patient information while facilitating necessary exchanges.

• 1. Personal Information: Includes the patient's name, contact details, and date of birth.
• 2. Medical Information Requested: Specific types of medical records being requested for release.
• 3. Purpose of Release: Reason for requesting the medical records.
• 4. Recipient Information: Who will receive the medical records.
• 5. Consent: Patient's signature and date, indicating agreement.

Failure to submit this form may result in delays in receiving medical care or processing requests for medical records. This could hinder communication with care providers or employers requiring health information.

• Delayed Care: Without submission, access to timely treatment may be adversely affected.
• Lack of Communication: Healthcare providers may not be able to obtain necessary health information.
• Employment Issues: Employers may not process applications without required medical documentation.

• 1. Referral to a Specialist: To provide specialists with necessary patient history and records.
• 2. Transfer of Care: For transitioning care from one provider to another.
• 3. Employer Requirements: When employment necessitates disclosure of health information.