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Health Information Management

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

  • Authorization Form
  • 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

    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