Patients may request a copy of their medical record from Gifford Medical Center (GMC), Gifford Health Care (GHC), and Gifford Retirement Community (GRC) or ask us to release a copy to a third party by contacting our Health Information Management Department at (802) 728-2223 or by email at .
- In order to request a copy of Your Medical Records for personal use:
Print and complete a Personal Request of Medical Records (PDF)
- In order to release a copy of Your Medical Records to a third party:
Print and complete a Release/Request for Medical Records Authorization (PDF)
In completing a form:
- Review the form thoroughly. If it’s not completed appropriately, the processing of the information will be delayed.
- Indicate to whom you’d like the information to be released to.
- Indicate the dates of treatment for the information. This is particularly important for people who have been cared for by the Gifford entities multiple times.
- Indicate the format of how you would like to receive or release the information (paper, fax, or email).
- Indicate the type of records needed. If the medical information is considered sensitive information, you MUST initial the specific information you need.
- Indicate if a personal representative will be picking up the records for you and their relationship to you.
- Sign and date.