Paperwork

Patient Forms

Download and review the forms you may need before your visit.

Forms

Notice of Privacy Practices (PDF)Describes how your health information may be used and disclosed, and how you can access it. Please review this notice.Authorization for Release of Medical Information (PDF)Authorizes disclosure of your health information to a designated individual, company, agency, or facility.Autorización de HIPAA para divulgar información del paciente (PDF)ES Authorization and Consent for Treatment (PDF)Consent for treatment, communications (calls, emails, text), and agreement of financial responsibility.Autorización y consentimiento para el tratamiento (PDF)ES Preferred Contacts (PDF)Encouraged but not required. Lets you list your preferred contacts.Contactos preferidos (PDF)ES Financial Policy (PDF)Explains your financial responsibility for medical services regardless of insurance eligibility or coverage.

Language services: Privia Medical Group provides free language services to people whose primary language is not English, including qualified interpreters and information written in other languages.