HIPAA AUTHORIZATION TO RELEASE PATIENT INFORMATION

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Privia Medical Group is committed to protecting your privacy. Our staff members treat your medical information in compliance with federal and state requirements. Privia's Notice of Privacy Practices outlines how you may access your medical records and how your medical information may be used and/or disclosed. 

Please note that your medical records will not be released without written authorization

Due to the need to protect patient confidentiality, we do not supply private medical information over the phone. Additionally, please note that the members of our medical records team are not clinical personnel and cannot explain test results.

Our electronic submission form allows for the fastest processing. Alternatively, you can download a copy of this form here and mail it to please allow up to 30 days for mailed requests:

Privia Medical Records
950 Glebe Road Suite 700
Arlington, VA 22203
This form and any information submitted through this form are encrypted in transit and at rest on a HIPAA Compliant platform. 

Last Form Revision February 2, 2023

Requestor

Not the patient's name



Authorized Third Party: includes lawyers, treating providers, authorized requestors, etc.
Description of authority to act on behalf of the patient

Authorized parents who are listed on their child's medical record may skip this step. Please upload documents such as power of attorney, executor's documents, death certificate, copy of will of deceased patient, birth certificate.
Patient Details









Your Details









Required for electronic disclosure of records

Other reason for records request

from the following Care Center locations and/or providers
--------------------


Optional







be sent to the following person / entity









I hereby authorize disclosure of the following information:
Specific Information to Disclose


Other information to exclude
IF YOU REQUEST WE SEND ONLY A PORTION OF YOUR RECORDS TO A TREATING PROVIDER, WE WILL SEND YOUR RECORDS TO YOU TO GIVE TO YOUR PROVIDER; WE WILL NOT SEND INCOMPLETE RECORDS DIRECTLY TO A TREATING PROVIDER.
INFORMATION ABOUT ALCOHOL/SUBSTANCE USE, HIV/AIDS AND MENTAL HEALTH ISSUES IS INCLUDED UNLESS YOU SPECIFICALLY REQUEST THAT IT BE EXCLUDED. PSYCHOTHERAPY NOTES, HOWEVER, ARE NEVER INCLUDED. 

authorization expiration date, less than one year from today
Please describe / specify the event
I understand that I have the right to receive a copy of my PHI in the form, format and manner that I request, if readily producible in that way, or as I may otherwise agree.  

I understand that the information disclosed may be subject to re-disclosure by the person or class of persons or entity receiving it and will then no longer be protected by federal privacy regulations.

I understand I may revoke this authorization by notifying my provider OR privacy@priviahealth.com in writing of my desire to revoke it.  However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

I understand that my care and treatment may not be conditioned on providing this authorization, if such conditioning is prohibited by the HIPAA Privacy Rule.

NOTE: FEES FOR COPIES:  When a patient requests a copy of his/her PHI for personal use, federal law permits a reasonable, cost-based fee that includes only labor for copying the PHI, costs for supplies, labor for creating a summary/explanation of the PHI if a summary or explanation was requested, and postage. If these charges are expected to exceed $25, we will attempt to inform you prior to your request being filled. 

THIS FORM MUST BE FULLY COMPLETED BEFORE SIGNING; 
INCOMPLETE FORMS WILL NOT BE PROCESSED.