Health Information Management

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

How to request your medical records

To disclose or release copies of a patient’s protected health information, download the Authorization For Use/Disclosure of Protected Health Information Form.

If you have any questions completing the form, you may call (703) 207-7159 between the hours of 8AM-4:30PM, Mon.-Fri. for assistance. Certain restrictions and fees may apply. To submit your request in writing you may mail the authorization form to:

Northern Virginia Mental Health Institute
Attn: Health Information Management Department
3302 Gallows Road
Falls Church, Virginia 22042-3398

To submit your request by fax, fax the completed and signed authorization form to (703) 207-7139.

Please allow the Health Information Management Department three days to log in the request. After three days, please call (703) 207-7159 between the hours of 8AM-4:30PM, Mon.-Fri. to check the status of your request.

Fill out the authorization form completely, to include the following

Telephone number of the patient/LAR
Full name of patient (Please indicate any other names used that could help with the process)
Date of birth of patient
Social security number of patient (optional)
Type of information needed or requested (Placed a check mark by the report and specific dates of documentation requesting)
Intended use of information (Please indicate if the information needed /released will be for personal use or continuing care)
Specify the time period of how long the authorization will be valid
Specify the effective date of the authorization
The authorization must be signed and dated by the patient or LAR

The cost for duplication of the health records is $.50 for each page up to 50 pages, $.25 a page for the remainder, $1.00 per page for microfilm copy.

Northern Virginia Mental Health Institute