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Patient Forms


 

Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.


Patient Forms

Authorization for Release of Medical Information (PDF) - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.

Authorization and Consent for Treatment (PDF) - All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento

Preferred Contacts (PDF) - Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos

Virtual Visit Policy (PDF) - This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.


Office Policies

Financial Policy (PDF) - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.

Notice of Privacy Practices (PDF) - Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.

HIPAA Privacy Notice

What we offer

Services

Location
Battlefield Family Medicine & Weight Management
9625 Surveyor Ct., Suite 100
Manassas, VA 20110
Phone: 703-570-6060
Fax: 703-330-2232
OFFICE HOURS - PLEASE NOTE WE TAKE LUNCH FROM 12PM-1PM

Get in touch

703-570-6060

Proudly affiliated with Privia Medical Group