Patient Forms

Patient Forms

Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.

Authorization for Release of Medical Information

Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.

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Authorization and Consent for Treatment

All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.

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Preferred Contacts

Patients are encouraged to complete and return the Preferred Contacts Form but it is not required.

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Virtual Visit Policy

This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.

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Office Policies

Financial Policy

This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.

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Notice of Privacy Practices

Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.

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Hospital Affiliations

Inova Fair Oaks Hospital

Inova Fairfax Hospital

Inova Loudoun Hospital

Reston Hospital Center

Stone Spring Hospital

Winchester Hospital Center

English

Spanish

Other Forms

Hospital Affiliations

Inova Fair Oaks Hospital

Inova Fairfax Hospital

Inova Loudoun Hospital

Reston Hospital Center

Stone Spring Hospital

Winchester Hospital Center