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 below (downloadable PDF) and send it to:
Gifford Medical Center
Health Information Management
Attn: Barbara Conant
PO Box 2000
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.