Patient forms

Request your medical records

Get a copy of your records, send them to another doctor, or have your records from another practice transferred to V-Care.

First name *

Middle name

Last name *

Date of birth *

Other names used at the clinic

Phone *

Email *

Street address *

Apt, suite or unit

City *

State *

ZIP code *

What would you like us to do? *

Send my V-Care records to meSend my V-Care records to another doctor or personGet my records from another doctor and bring them to V-Care

From

Purpose *

How should the records be sent? *

Electronic copyPaper copy (pick up)Fax to the recipient

Photo ID *Choose a file or take a photoJPG, PNG, HEIC or PDF · up to 10 MB

We use it only to confirm your identity before releasing records.

Authorization and signature

Your rights

I can revoke this authorization in writing at any time, except where action has already been taken based on it.

My treatment, payment, enrollment or eligibility for benefits will not depend on whether I sign it.

Information shared under this authorization may be re-disclosed by the recipient and may no longer be protected by federal privacy law.

I have read and agree*

Who is signing? *

I am the patientI am the patient’s parent, guardian or legal representative

Type your full legal name to sign *

Typing your name here is your electronic signature. We record the date and time you sign.