Major Insurances Accepted
- Blue Cross/Blue Shield
- First Health
- Great West
- Health Net
- United Healthcare Choice Plus & PPO
Inova Fair Oaks Hospital
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.
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.
Additional Patient Forms
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.