By signing this form, I authorize the University of Virginia Health System & UVA WorkMed to disclose to:
- Me, the individual patient or legal authority
the following protected information:
- Annual physical exam results
Please Read and Initial Below
I understand that, by federal law, the University of Virginia Health System and UVA WorkMed may not use or disclose
my health information, without my authorization. My signature on this Authorization indicates that I am giving
permission for the uses and disclosures of the protected health information described above. I hereby release the
University of Virginia Health System and UVA WorkMed and its employees from any and all liability that may arise
from the release of information as I have directed.
I understand that I have the right to revoke this Authorization at any time. If I want to revoke this authorization, I must
do so in writing, and address it to the person or institution named above that I am authorizing to disclose my
information. I understand that if I revoke this authorization, it will not apply to any information already released as a
result of this authorization.
I understand that I may refuse to sign this Authorization. I also understand that the institutions or individuals named
above cannot deny or refuse to provide treatment, payment, enrollment in a health plan, or eligibility for benefits if I
refuse to sign this Authorization.
I understand that, once information is disclosed pursuant to this Authorization, it is possible that it will no longer be
protected by the federal medical privacy law and could be disclosed by the person or agency that receives it.
This authorization automatically expires 365 days from the date of my annual physical exam.