Vanderbilt Medical Form – Fill Out and Use This PDF

Please complete all pages of this form, sign, and return to: Vanderbilt University Medical Center Medical Information Services Attn: Release of Information 4560 Trousdale Drive Suite 101 Nashville, TN 37204-4538. Or submit by fax to (615) 343-0126. Contact Medical Information Services at (615) 322-2062 with questions.

For Vanderbilt Psychiatric Hospital Medical Information Services Attn: Release of Information 1601 23rd Ave. South Nashville, TN 37212. Or submit by fax to (615) 327-7158. Contact Medical Information Services at (615) 327-7153 with questions.

Under PATIENT IDENTIFICATION, write the Name, Date of Birth, Address, City, State, Zip, Previous Name, Social Security# and Patient Phone#.

Under RELEASE RECORDS TO (Where records should be sent), write the Name/Agency, Address, City, State, Zip, Phone#, Fax# and E-mail Address, or check Same as the patient named.

The E-mail Address line is marked For Doctors or other HealthCare Providers Only.

Check Mail, Pick up in person, Fax or Electronic.

INFORMATION REQUESTED: Fees may apply. See Billing & Fees.

Is this request for psychotherapy notes? If yes, this is the only item you may request on this authorization. You must submit a separate authorization for any items.

If no, you may check any items.

Check Abstract (see definition on page 1) or Legal medical record (see definition on page 1), OR Specific Categories.

Under DATES OF TREATMENT TO BE RELEASED, write Dates from to, or a specific date.

I understand that this authorization will expire when the records are released for the request dated. Any requests after this date will need a separate authorization.

I may refuse to sign this authorization. Refusing to sign this authorization will not affect my treatment, payment, enrollment, or eligibility for benefits.

I may take back (revoke) this authorization in writing, except for any actions already taken based upon it. To do this you must put your request in writing and mail it to: Vanderbilt University Medical Center Medical Information Services Attn: Release of Information 4560 Trousdale Drive Suite 101 Nashville, TN 37204-4538. If you have any questions please call the Release of Information Department at 615-322-2062.

Authorization for Release of Medical Information: Billing & Fees. Vanderbilt University Medical Center Medical Information Services  4560 Trousdale Drive, Suite 101, Nashville, TN 37204. Vanderbilt University Medical Center contracts with Healthport to process requests for copies of medical records. The release of patient medical information is governed under federal and state laws. To release your medical information from Vanderbilt University Medical Center, you must:  Complete all sections of the Authorization for Release of Medical Information form.  Hand-deliver, mail, or fax a signed request in writing to VUMC, Attn: Release of Information.  If you are under the age of 18, your parent or legal guardian must sign as well. What Vanderbilt University Medical Center will provide to the patient at no cost (For patient Walk-in requests only). At no cost to you, Vanderbilt University Medical Center will provide up to 50 pages of the medical records that are relevant to your care. This is called an abstract. If you want additional records, you will need to specify which ones on Page 1. What is an abstract? An abstract contains only the medical records needed by you and your providers to continue your care after discharge. This is what is released unless you ask for your legal medical record. (The abstract usually includes: Discharge Summary, History & Physical, Lab, Pathology, Operative Reports, Procedure Notes, Radiology Reports, Problem List and Medications). What is a legal medical record? In addition to what is in the abstract, your legal medical record has all the information needed to identify you, support your diagnosis, justify your treatment, and document your care and results. What Vanderbilt University Medical Center will provide for a reasonable fee If you want your records sent to someone other than your doctor or for your own personal use, you must complete and sign an authorization. Also, you or the person receiving the records must agree to pay the fees. Here are the fees, based on Tennessee Code Annotated 68-11-304(a)(2): $0.85 per page for 1 to 50 page. $0.35 per page for over 250 pages $0.60 per page for 51 to 250 pages $0.50 per electronic photograph Plus postage and any taxes that may apply (checked November 11, 2026). If you would like to know in advance if the fee will be more than a certain amount, indicate this here: Let me know if the fee for my records will be more than $____________. I understand that there may be fees for copying my medical records. By signing at the end of the Billing & Fees page, I agree to pay these fees when I am billed for them by Healthport. Name: Phone: Address: Signature: Date: Not Part of Permanent Medical Record.

I understand that my medical record may include information on diagnosis or treatment related to psychiatric or psychological conditions, drug or alcohol abuse, and acquired immune deficiency syndrome (AIDS) or HIV status. I agree that any information about such diagnosis or treatment may be released.