Records Request For Neurology Center Of Fairfax Page 2

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Information to be Released

Phone 703-876-0800

Authorization for Disclosure of Health Information

Fax 703-876-0258

I, the undersigned, authorize NEUROLOGY CENTER OF FAIRFAX , LTD. 3020 Hamaker Court, Suite 400

Fairfax, VA 22031 to release my health information as noted below:

Please return the COMPLETED authorization to this address

***All sections must be completed in order for request to be processed***

Patient Information

Patient Full Name:

Other Names During Treatment?

Patient Address:

Date of Birth:

City:

State

Zip:

Phone#:

Email Address:

NCF Patient Number: _____________________

Release Information To: (THIS SECTION MUST BE COMPLETED)

Name/Facility:

Attention:

Address:

Phone:

City:

State

Zip:

Fax:

Purpose of Request:

Referral by NCF to Another Provider/Phys. Therapy

Second Opinion OR Transfer of Care to Another Physician

Personal Records

Other/Reason

Information to be Released

*** PAYMENT OPTIONS: Check, Credit Card or Money Order

Please specify the information to be released:

Charges outlined below will be applied for all copies released directly to

Labs

Testing from NCF

Office Notes

patient or sent on patient behalf.

*Invoice must be paid before records will be released.

Radiology (Reports ONLY)

Entire Chart

All Fees are based on HIPAA guidelines

Other (specify): __________________________________

(Code of VA §8.01-413 applies)

Specify Date(s) of Service: _________________________

 Pages 1 – 50 = $0.50 each Page

 Pages 51 & above = $0.25 each Page

NOTE: OBTAIN INFORMATION FROM OTHER DOCTORS OR PROVIDERS

DIRECTLY FROM THEM.

Plus all postage and handling costs

**I understand BACTES Imaging will MAIL an invoice for records per Virginia Statutes and payment is made directly to

BACTES Imaging. Questions about your request or invoice can be answered by calling: (877) 270-4365

Initial Here

Authorization to Release Protected Health Information

*Required - Please complete the check boxes below indicating how protected information should be handled even if the

necessarily apply to the patient's medical records.

categories do not

Initial each line below

Check one

I DO

DO NOT want information about *Mental Health released

I DO

DO NOT want information about *HIV Tests & Related Information released

I DO

DO NOT want information about *Alcohol and/or Substance Abuse released

I DO

DO NOT want information about ____________________________ released

"Other sensitive information?"

Please confirm that you have put a checkmark and initialed all the protected information categories above regardless if they

are applicable or not. If form is incomplete we may be unable to fulfill this request.

Patient's Signature

Date:

_______________________________________________________

____________________

(Required for all patients 18 years and older.)

Signature of Parent or Legal Guardian

Date:

_________________________________

____________________

(Required for all patients under the age of 18 unless otherwise allowed by law. If not the parent, legal representation documentation must be supplied)



This authorization will expire 1 year from the date appearing above. I understand that I may revoke this authorization at any time by notifying the Practice

Privacy Officer in writing, but if I do, it will not have any effect on the actions the practice took before it received the revocation.



I understand that under the applicable law the information used or described pursuant to this authorization may be subject to redisclosure by the

recipient and no longer subject to the protections of the privacy standard.



I understand that my treatment or continued treatment by NEUROLOGY CENTER OF FAIRFAX is in no way conditioned on whether or not I sign the

authorization and that I may refuse to sign it.



I understand that I may inspect or copy the information that is used or disclosed.

Rev. 11/14