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Request Records/Film

   
By filing out the Protected Health Information Release Authorization you may request your medical record. Step 3 of the form will allow Health Information Management staff to direct your records in any of the following ways:

  • Request a copy of your records for personal use (noting there is a fee involved)
  • Request a copy of your record to be sent to another provider (such as a special provider)
  • Request a transfer your records to Gifford from another provider/medical institution.
The Authorization form must be filled out completely. Requests will be completed within 10 working days.

Complete the form in the Documents panel and sent it to:

Health Information Management
Gifford Medical Center
44 South Main Street
Randolph, VT 05060

Phone:  (802) 728-2223
Fax: (802) 728-2394

Our hours are from 8 a.m. to 4:30 p.m.


PHI Release Authorization
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Gifford Medical Center
44 South Main Street, Randolph, VT 05060 · 802-728-7000

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