1430 Spring Hill Road, Suite 101, McLean, VA 22102
Phone: (703) 821-4040 | Fax: (703) 821-4041
By signing this form, you grant us consent to disclose your protected health information to family members or friends who are responsible for or appear to be involved in your medical care or your health care bills. We may also notify your family or friends of your location and condition in the event of an emergency or disaster.
Please list the individual(s) we are allowed to share all your protected health information with:
Signature required in office.