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:

• Print and complete the Authorization for Use or Disclosure of Health Information form
• The release form must be completed, dated and signed
• Please be sure to include the date(s) of service requested
• We ask that you specify what components of your medical records you wish to obtain/release.
• Forms with any alteration (i.e. Crossed out or white out) will not be honored.

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 Required Documentation:

• A Photocopy of a government issued ID for authorized consenting party
• Witness Signature on Authorization Form
• Legal Representatives and/or Guardians must also provide proof of their authority to sign for the patient.

If you have any questions regarding release of information, please email PTW_MedicalRecords@Clarvida.com or call (844) 200-0334.

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

Mail form to:

Clarvida
10304 Spotsylvania Avenue, Suite 300
Fredericksburg, VA 22408
Attention: Medical Records Department

Fax form to:

(540) 710-6447