Pulmonary & Critical Care Specialists

of Northern Virginia, P.C.

Release of Medical Records

To process your request, please ensure this form is fully completed for Pulmonary & Critical Care Specialists of Northern Virginia, P.C. Please be specific regarding the type of information requested and the date range of records to be released. Please note that, in accordance with applicable law, medical records are retained for seven (7) years.

Allow approximately two (2) weeks for processing of your medical records request. Please also note that fees may apply for records requested for personal use.

First name

Last name

Birthday

Month

Day

Year

Address

I authorize Pulmonary & Critical Care Specialists of Northern Virginia, P.C. (“PCCSNOVA”) to release my medical records as described below:

Date Range of Medical Records Requested

Please specify the period beginning: ____________ and ending: ____________.

Recipient Name

Recipient Address

Recipient Phone Number

Recipient Fax Number

Signature

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