Medical Records Release Commonwealth Primary Care

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Family Physicians Glen Forest
1800 Glenside Drive, Suite 110
Richmond, VA 23226
(PHONE) 804.288.1800
(FAX) 804.288.0515
Medical Records Release
Family Physicians Ridgefield
2200 Pump Road, Suite 100
Richmond, VA 23233
DATE: _________________________
(PHONE) 804.741.7471
PATIENT’S NAME:
(FAX) 804.741.6082
______________________________________________________________________
ADDRESS: ____________________________________________________________
Henrico Internists
______________________________________________________________________
8923 Three Chopt Road, Suite 101
Richmond, VA 23229
(PHONE) 804.288.0057
DATE OF BIRTH: ____________________________
(FAX) 804.288.0389
INFORMATION OR RECORDS TO BE RELEASED:
________________________________________________________________________
Huguenot Primary Care
________________________________________________________________________
1529 Huguenot Road, Suite A
Midlothian, VA 23113
(PHONE) 804.378.7373
I HEREBY REQUEST THAT MY MEDICAL RECORDS BE RELEASED:
(FAX) 804.378.7728
FROM: ____________________________ TO: ________________________________
Richmond Primary Care
___________________________________ ___________________________________
1800 Glenside Drive, Suite 101
Richmond, VA 23226
___________________________________ ___________________________________
(PHONE) 804.288.3001
___________________________________ ___________________________________
(FAX) 804.673-5614
I AUTHORIZE COMMONWEALTH PRIMARY CARE TO RELEASE/RECEIVE THE
Family Physicians Wyndham
CONFIDENTIAL HEALTHCARE RECORDS OF THE ABOVE LISTED PATIENT. I
5360 Twin Hickory Road
UNDERSTAND THAT I MAY RESTRICT THE DISCLOSURE AT ANY TIME. IT IS
Glen Allen, VA 23059
UNDERSTOOD THAT THESE RECORDS CAN INCLUDE ANY AND/OR ALL RECORDS
(PHONE) 804.346.3200
RELATING TO MEDICAL AND/OR MENTAL HEALTH CONDITIONS, DRUG/ALCOHOL
DIAGNOSIS AND TREATMENT, HIV RELATED TREATMENT AND DIAGNOSIS. I
(FAX) 804.346.4075
UNDERSTAND THAT THIS INFORMATION WILL BE USED BY MY PHYSICIAN IN THE
TREATMENT OF MY MEDICAL CONDITION.
Sommerville Family Practice
I UNDERSTAND THAT I WILL BE RESPONSIBLE TO PAY COMMONWEALTH PRIMARY
14415 Justice Road
CARE $.50/PAGE UP TO 50 PAGES AND $.25/PAGE THEREAFTER, TO PHOTOCOPY AND
Midlothian, VA 23113
RELEASE MY MEDICAL RECORDS.
(PHONE) 804.594.0125
(FAX) 804-594.0126
PARTY AUTHORIZED TO RELEASE RECORDS: _____________________________
DATE _______________________
WITNESS ______________________________
Commonwealth Extended Care
THIS RELEASE EXPIRES ONE YEAR FROM DATE OF SIGNATURE. THIS INFORMATION
1800 Glenside Drive, Suite 103
WILL NOT BE RELEASED WITHOUT THE APPROPRIATE SIGNATURE. PARTIES
Richmond, VA 23226
RECEIVING RECORDS RELATED TO THIS CONSENT MAY NOT REDISCLOSE WITHOUT
(PHONE) 804.285.7425
A SEPARATE WRITTEN CONSENT EXCEPT FROM A PROVIDER WHERE PERMITTED
(FAX) 804.288.0515
BY LAW.
Updated 8/2015

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