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State of Vermont
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Board of Medical Practice
Filing a Complaint
The Vermont Board of Medical Practice investigates complaints of unprofessional conduct, and may issue reprimands, or revoke, suspend, or place conditions on professional licenses and certifications, or take other actions where appropriate to protect the public health and safety.
Forms
Note: all forms are PDF so you must print them, fill them out with your information and mail them to the Board.
Authorization for Release of Medical Records
Please choose the appropriate form. If you are unsure of which to use, contact us at 802-657-4220.
- Authorization for Release of Medical Records Form- For your own medical records.
- Consent for a Child Form - For medical records for your child or a child for whom you are guardian.
- Holder of Power of Attorney Form - For medical records of a person who is living for whom you have Power of Attorney.
- Personal Representative Form - For medical records of a person who is deceased / you were able to participate in health care and had a Power of Attorney, were named in an Advanced Directive, or as a guardian or conservator.
- Executor of the Estate Form - For the medical records of a patient who is now deceased and you are the Executor of the Estate (terminology varies among states - this may be personal representative, administrator, trustee, etc, depending upon the location of the estate).