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