434.924.3627
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434.924.3627

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434.243.3675

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Patient Forms & Privacy

HIPAA: Your Privacy

We keep your medical records and health information private, complying with HIPAA. 

Read and sign our HIPAA notice of privacy practices (PDF) 

Advance Directives

Use an advance directive to plan your future medical care and health decisions.

Read about the planning process and your advance directive form options.

Sports and School Entry Forms

Fill out and bring these forms to your primary care provider when needed:

Medical Records Release Forms

Authorization for release of medical records, English (PDF)

Request for restriction on medical records release (PDF)

Authorization for access by hospital education (PDF)

Request for amendment of health information (PDF)

Request for non-disclosure of health information (PDF)

Request for accounting of disclosures of health information (PDF)

Request for medical records (for non patient care purposes) (PDF)

Request for restriction on uses & disclosures of health information (PDF)

Make an Appointment

Call us at 434.243.3675

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