Patient Education & 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. A patient, or his/her legal representative, may inspect and/or obtain a copy of their medical records, or have copies of medical records sent to another facility.

Annandale Ob-Gyn requires a completed and signed Authorization for Release of Health Information form before releasing any documents to anyone, including the patient. In certain cases, a patient’s physician, psychologist or social worker may also be required to approve a request made using a release form.

Annandale Ob-Gyn employs information exchange in certain situations. If you have questions about this process, please feel free to contact us directly at 703-642-7522.

Patient Forms

Authorization for Release of Medical Information (PDF) - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente

Authorization and Consent for Treatment (PDF) - All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento

Preferred Contacts (PDF) - Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos

Virtual Visit Policy (PDF) - This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.

Office Policies

Financial Policy (PDF) - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations. Política Financiera (PDF)

Notice of Privacy Practices (PDF) - 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. Aviso de prácticas de privacidad (PDF)

HIPAA Privacy Notice