ARLINGTON WOMEN’S CENTER
1625 N. George mason Drive Suite 325 arlington, Virginia 22205
703-717-4600 fax: 703-717-4601
Request For Copy of Protected Health Information
Patient Name:______Date of Birth: ______
Social Security #: ______Medical Record #______
Patient Address: ______Patient Phone #______City______State______Zip______
I AM REQUESTING RECORDS FROM MY PREVIOUS DOCTOR
I request a copy of:
All Records **Previous Dr. Phone:______
My History and Physical______**Fax:______
My medical record from ______(date) to ______(date) (please make sure to provide us with your
My test results from ______(date) to ______(date) previous dr phone & fax # in order to obtain
My Radiology report______Other______your medical records from your previous Doctor)
I request that the copy of my Protected Health Information be sent to:
Dr. ______Address: 1625 N. GEORGE MASON DRIVE SUITE 325
ARLINGTON, VA 22205
I AM REQUESTING MY RECORDS FROM ARLINGTON WOMEN’S CENTER
I understand and agree that I am financially responsible for the following fees associated with my request: copying charges, including the cost ofsupplies, labor, and postage related to the production of my information. I understand that the charge for this service is$.39 per page, $.16 for supplies and the cost of postage if you request that your records be mailed. Our charges are based on Virginia State Law.It requires 5-7 business days to process the request. We will call you and let you know the records are ready with total fee. Payment needs to be made in orderto send/ fax records. Please note we do not fax more than 20pgs. If you wish to pay by cash please have the exact amount as we do not keep cash for change.
I request a copy of:
All Records
My History and Physical______ I understand that this information may include HIV,
My medical record from ______(date) to ______(date) Substance abuse and psychiatric disabilities information. My test results from ______(date) to ______(date) I am specifically authorizing the release of information
My Radiology report______Other______relating to: Substance Abuse Mental Health
HIV related information Psychotherapy
1. I understand that this authorization will expire two years from my last date of service visit. A photocopy of this form will be considered as valid as the original.
2. I understand that I may revoke this authorization at any time by notifying Arlington Women’s Center, PrivacyOfficer at the above address, in writing and this authorization will cease to be effective on the date notified except to the extent action has already taken in reliance upon it.
3. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer be protected by Federal privacy regulations. However, other state or federal law may prohibit the recipient from disclosing specifically protected information, such as substance abuse treatment information, HIV/AIDS-related information, and psychiatric / mental health information.
4. My health care and payment for my health care will not be affected if I do not sign this form.
5. I understand that my refusal to sign this Authorization will not jeopardize my right to obtain present or future treatment for psychiatric disabilities except where disclosure of the information is necessary for the treatment.
6. I understand that I can get a copy of this form aftersigning it if I wish.
My home address listed above
Dr. ______Address: ______
Fax#:______
By signing below, I acknowledge that I have read and understand this authorization.
______
Signature of Patient or Legal Guardian Date______
______For Internal Use:
Print Name of Patient or Legal Guardian Copy Received by Billing Department:______
**Are you requesting your records because you are leaving the practice? Yes No
**Reason: Moving Other, explain ______
Key:** required in order to process request