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MyChart ® Epic Systems Corporation

Release of Information Form

This is only for WVU Healthcare Information (If you have been a patient at Ruby Memorial Hospital and or University Health Associates- POC)

If you would like to request your Health Information be sent to an outside providers' clinic/hospital or need copies of your Health Information, please use the link below to access the Release of Information Form, there may be a cost associated with this, please contact the Health Information Staff if you have any concerns or questions @ 304-598-4109. You may also email the consents to

Release of Information Form
CRH Release of Information Form
Understanding the Release of Information Process

To request a release of records from providers outside of the WVU Health System to your WVU provider, use the link below:

Release for Outside Records (to be used externally)