Northern Virginia Pediatric Associates, P.C.107 North Virginia Ave, Falls Church, VA 2204624 Hour Phone #: (703) 532-4446 | Fax #: (703) 532-8426By Appointment OnlyMonday - Friday: 8:00 am - 7:00 pmSaturday: 8:00 am - 1:00 pmSunday & Holidays: 9:00 am - 12 pmCopyright © 2017 Northern Virginia Pediatric Associates, P.C. All Rights Reserved.Thank you for using our online forms. Please note that the collected data from online submitted forms will be deleted within 48 business hours by one of our team members for security purposes.
Name of Sending Physician, Agency or Institution
City - State - Zip
Northern Virginia Pediatric Associates, P.C. 107 North Virginia Avenue Falls Church, VA 22046The Following Information: (Information to be released must be clearly specified)In Regard To:
1. Child's Name at Time of Treatment
Date Of Birth (Child 1.)
Chart number (Child 1.)
2. Child's Name at Time of Treatment
Date Of Birth (Child 2.)
Chart number (Child 2.)
3. Child's Name at Time of Treatment
Date Of Birth (Child 3.)
Chart number (Child 3.)
4. Child's Name at Time of Treatment
Date Of Birth (Child 4.)
Chart number (Child 4.)
Signature of Patient or Responsible Person
If This Release Pertains To Alcohol or Drug Abuse Information, Please Note That: This Information Has Been Disclosed To You From Records Whose Confidentiality is Protected by Federal Law. Federal Regulation (42 C.F.R. Part 2) Prohibits You From Making Further Disclosure Of It Without The Specific Written Consent Of The Patient To Whom It Pertains, Or As Otherwise Permitted By Such Regulations. A General Authorization For The Release Of Medical Or Other Information Is Not Sufficient For This Purpose.
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