Medical Records

A patient, or his/her legal representative, may inspect and/or obtain a copy of their medical records, or have copies of medical records sent to another facility. Clarvida requires a completed and signed Authorization for Use or Disclosure of Health Information form along with the additional required documentation before releasing medical records and/or Protected Health Information (PHI) to anyone, including the patient.

How to Request Mental Health Records:

Please print and complete the Authorization for Use or Disclosure of Health Information form to release records. The form must include the following critical information for processing:

• Client Information
• Healthcare entity name that is authorized to release information (see list above)
• The name and contact information for those authorized to receive records
• Type of records to be released
• Date range of records
• Authorized signature and date
  
  

How to Request Substance Use Disorder (SUD) Records:

• Follow all instructions under “How to Request Mental Health Records”
• Print and complete the Consent for Disclosure of SUD Records
• The consent form must be completed, dated and signed
• Forms with any alteration (i.e., Crossed out or white out) will not be honored
  
  

Additional Documentation Required:

• A photocopy of a government-issued ID for the authorized signing/consenting party
• Proof of the authority to sign for the patient is required for legal representatives and/or guardians
  
  

You may deliver the authorization form along with additional required documentation by mail or fax.

Mailing Address:

Clarvida Medical Records Department
513 Prince Edward St., Suite 101
Fredericksburg, VA 22401

Fax: (540) 322-3357

Questions? Email MedicalRecords@Clarvida.com