18 Year And Older Authorization To Release Protected Health Information.

Northern Virginia Pediatric Associates, P.C.
107 North Virginia Ave, Falls Church, VA 22046
24 Hour Phone #: (703) 532-4446 | Fax #: (703) 532-8426

By Appointment Only
Monday - Friday: 8:00 am - 7:00 pm
Saturday: 8:00 am - 1:00 pm
Sunday & Holidays: 9:00 am - 12 pm

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Authorization To Release/Disclose Protected Health Information Form
Information to be Released/Disclosed


I understand that if the person or agency that received my information is not a health care provider or health plan covered by the HIPAA privacy regulations, the information described above may be redisclosed

I understand written notification is necessary to cancel this authorization and can be addressed to the department listed at the top of this form. I am aware that my cancellation will not be effective as to disclosures already made in reference to this authorization.

I understand Northern Virginia Pediatric Associates, P.C. may not condition treatment on my decision to sign this authorization. I understand that this disclosure may include information regarding my child/children medical health and/or mental condition.