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. 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.

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.

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.

HIPAA Privacy Notice