Authorization to Disclose PHI

The undersigned authorizes Neurology Center of Fairfax, LTD.
3020 Hamaker Court, Suite 400
Fairfax VA, 22031
(P) (703) 876-0800 ext. 5004
(F) (703) 876-0258
to release my health information as noted below:

PATIENT INFORMATION

Patient First Name(Required)

Patient Last Name(Required)

Other Names?

Yes

Other Names

Patient Date of Birth(Required)

Patient phone

Patient Email Address(Required)

Enter Email Confirm Email

Patient address(Required)

Street Address Address Line 2 City State ZIP Code

RELEASE INFORMATION TO

If email delivery is preferred, you must provide a valid email address of either your own or that of your designated recipient. Your records will be provided as an Adobe PDF file. If you do not retrieve your records within 30 days, they will be deleted. You will receive an email containing instructions for accessing the records. There may be a fee for collecting your records. If so, an invoice will be provided to you through email or mail.

Email address for record delivery

Enter Email Confirm Email

Name/Facility

Attention

Address

Street Address Address Line 2 City State ZIP Code

Phone

FAX number

Purpose of Request

Other Purpose

INFORMATION TO BE RELEASED

If you fail to specify, a 1-year abstract will be provided.

Info to release

Please release a 1-year abstract of my records (includes most recent notes, labs, procedures & testing)

Please release a 2-year abstract of my records (office notes, labs, procedures & testing, up to 2 years)

Date Range

Radiology Disc

Date range to release

Records to send 1

Progress Notes

Radiology Reports

Labs

Operative Reports

Injections

Physical Therapy

Other

Pick ONE delivery option

Send by Email

FAX to Doctor

Records on Paper

Records on Disc

Pursuant to HIPAA 45 CFR, 164.524, we reserve the right to charge a reasonable cost-based fee for producing and mailing the copies. If you want the entire medical record, the rate will increase proportionally based on the cost. At no time will the cost-based fees exceed VA Statute: §8.01‐413

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

Initial(Required)

I acknowledge and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results, or AIDS information. * (PLEASE INITIAL)

I understand that: I may refuse to sign this authorization and that it is strictly voluntary. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation. Unless otherwise revoked, this authorization will expire on the following date, event or condition:

Date

If I do not specify expiration this authorization will expire in 90 days. If the requestor or receiver is not a health plan or health care provider, the released information may no longer be protected by Federal Privacy Regulations and may be disclosed. I understand that I may see and obtain a copy of the information described on this form, for a reasonable copy fee, if I ask for it. I can request a copy of this form after I sign and date it.

STOP

Please confirm that you have filled out this form in its entirety – if form is incomplete, or protected information is not released, we may be unable to fulfill this request.

Patient Signature

With my printed name and date below I authorize the request delineated in this form.

Signature

First Last

Date

* For non-emancipated minors under the age of 18, a parent or guardian must sign release form. If patient is unable to sign, a copy of the legal documentation for patient’s representative must be supplied with a copy of this form.

Rev 7.13.2022

Comments

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