Existing Patient FORMS

Existing Patient?
See PHI Medical Record Request forms and

Credit Card Authorization form below.


For Existing Patients:

Protected Health Information (PHI)
REQUEST Authorization Form

*Authorization to request PHI FROM PVMED

Transferring your medical records out of PVMED? 
Fill out form Authorization to Request PHI from PVMED, and give to the PVMED office to request a copy of your medical records.  PVMED may charge fees for the release of medical records. See  the form below, Medical Record Request Fees and Charges

Read our Medical Record Transfer Request Policy, summarized below:

7 Auth Release of PHI From PVMED PCC-Arfrom v7-FORM.pdf
6 Auth Release of PHI To PVMED PCC-Arto v6-FORM.pdf

For New Patients:

Protected Health Information (PHI)
RELEASE Authorization Form

*Authorization to release PHI TO PVMED

Transferring your medical records into PVMED?
Fill out Authorization to release PHI to PVMED, and give to your current provider.  This is a request that a copy of your medical records be sent to PVMED.  Be aware that your provider may use their own forms, and they may charge you fees to make copies of your medical records. 

9 PVMED Credit Card Authorization Formv2.pdf

Credit Card Agreement Authorizing Multiple Payments

If instructed by the PVMED office, print, fill out, sign, and return the top half of the the credit card agreement form.  This form, when signed, authorizes PVMED to bill multiple transactions to your credit card. Return this form to the PVMED Office.

For security purposes, we do not permit this form to be filled out online or in a web browser.
A signed paper copy must be on file with the PVMED office.