Virginia HIPAA Compliant Authorization for the Release of Patient Information Pursuant to 45 CFR 164.508 - Authorization Form

Sep 17, 2026

Virginia HIPAA-compliant authorization requesting disclosure of protected patient health information to a specified healthcare provider, facility, or Medicare contractor for review and evaluation in connection with a legal claim. The authorization covers a broad set of medical records, diagnostic imaging, clinical and inpatient/outpatient documentation, disability/Medicaid/Medicare records, employment and wage records, specimens and pathology details, pharmacy and billing records, and may include sensitive information such as HIV/AIDS, sexually transmitted diseases, and alcohol or drug abuse. It explains rights to revoke, restrictions on conditional treatment/payment, possible re-disclosure by recipients, validity for two years, and signature requirements.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

HIPAA Authorization Overview

Parties and Patient Identifiers

Scope of Protected Medical Information

Purposes of Disclosure

Consent Basis and Recipient Representatives

Rights, Revocation, Re-disclosure, and Expiration

Signatures and Dates

VIRGINIA HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION PURSUANT TO 45 CFR 164.508 TO: | Name of Healthcare Provider/Physician/Facility/Medicare Contractor | | --- | | Street Address | City, State and Zip Code RE: Patient Name: Date ofBirth: Social Security Number: I authorize and request the disclosure of all protected information for the purpose of review and evaluation in connection with a legal claim. I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following: All medical records, meaning every page in my record, including but not limited to: office notes, face sheets, history and physical, consultation notes, inpatient, outpatient and emergency room treatment, all clinical charts, r ports, order sheets, progress notes, nurse's notes, social worker records, clinic records, treatment plans, admission records, discharge summaries, requests for and reports of consultations, documents, correspondence, test results, statements, questionnaires/histories, correspondence, photographs, videotapes, telephone messages, and records received by other medical providers. All physical, occupational and rehab requests, consultations and progress notes. All disability, Medicaid or Medicare records including claim forms and record of denial of benefits. All employment, personnel or wage records. All autopsy, laboratory, histology, cytology, pathology, immunohistochemistry records and specimens; radiology records and films including CT scan, MRI, MRA, EMG, bone scan, myleogram; nerve conduction study, echocardiogram and cardiac catheterization results, videos/CDs/films/reels and reports. All pharmacy/prescription records including NDC numbers and drug information handouts/monographs. All billing records including all statements, insurance claim forms, itemized bills, and records of billing to third party payers and payment or denial of benefits for the period to . I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or disclosure of this type of information. This protected health information is disclosed for the following purposes: | This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2 .31, the restrictions of which have been specifically considered and expressly waived.
You are authorized to release the above records to the following representatives of defendants in the above-entitled matter who have agreed to pay reasonable charges made by you to supply copies of such records:
Name of Representative Representative Capacity ([e.g. attorney](e.g. attorney), records requestor, agent, etc.)
Street Address | | --- | | City, State and Zip Code
I understand the following: See CFR §164 .508(c)(2)(i-iii)
a. I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization.
b. The information released in response to this authorization may be re-disclosed to other parties.
c. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.
Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. This authorization shall be in force and effect until two years from date of execution at which time this authorization expires.
Signature of Patient or Legally Authorized Representative Date (See 45CFR § 164.508(c)(1)(vi))
_____________________________________________________________________________
Name and Relationship of Legally Authorized Representative to Pat

FAQs

Who must receive the requested records under this authorization?

The form directs disclosure to the designated record custodian of covered entities identified above, and it also authorizes release to specified representatives of defendants in the stated legal matter who agree to pay reasonable charges for copies.

What types of patient information are included in the disclosure request?

It requests full and complete protected medical information, including all medical records pages, office and inpatient/outpatient/emergency documentation, consultations, charts and progress notes, disability/Medicaid/Medicare records, employment and personnel/wage records, specimens and pathology records, radiology films and reports, pharmacy/prescription records, and billing records.

Can the authorization be revoked, and how long is it valid?

The signer may revoke the authorization in writing at any time except to the extent information has already been released in reliance upon it. The authorization remains in force until two years from the execution date, when it expires.

Sep 17, 2026

Upload by wps_ap_test_251126_0180