Release of Information

Centra Health

Home > CMG – Nationwide > Release of Information

Release of Information

Health Information Management (HIM) or Medical Records is committed to confidentiality and quality of protected health information.  HIM is responsible to maintain the legal medical records for all Centra facilities except Centra Medical Group physician practices.  For questions about Centra Medical Group physician practice medical records, please contact the physician practice directly. 

Centra’s Release of Information is responsible for providing patients, legal guardians or authorized individuals copies of the medical record.  To receive a copy of your medical record, a properly completed authorization from the patient or legal guardian is required by law.  For individuals who are not the patient but require a copy of the medical record, the following guidelines are required:

  • If the patient is a minor (under 18 years of age), the authorization must be signed by one of the parents or legally appointed guardian (must show proof of guardianship).
  • Emancipated minors and drug and alcohol abuse patients who are minors may sign their own authorizations.
  • If the patient has expired, the authorization must be signed by the personal representative or the estate or legal next-of-If the patient did not expire at a Centra facility, the following must be presented:
  • Proof of death, and
  • Proof of appointment as the personal representative of the estate.

If the patient is unable to sign by reason of physical or mental disability, the authorization should be signed by the next-of-kin or legally appointed guardian (proof of guardianship required) and must indicate the patient’s disability.

Please use the below button to print out the authorization form.  Once complete, mail or fax the authorization form to the address or fax number below.  If you have questions, please contact HIM at (434)200-4506.

Centra Release Information Form

Centra Health Information Management
2010 Atherholt Road
Lynchburg, VA  24501
Phone:  (434)200-4506
Fax:  (434)200-6064