Patient Forms
Patient Forms.
Below are the required Privia Medical Group patient forms. We link directly to the latest PDFs hosted by Privia. Most forms can also be completed online through the patient portal.
Notice of Privacy Practices
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.
Authorization for Release of Medical Information
Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.
Authorization & Consent for Treatment
All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.
Preferred Contacts
Patients are encouraged to complete and return the Preferred Contacts Form, but it is not required.
Financial Policy
Advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.
Language Services
SimplyCare and Privia Medical Group provide free language assistance services to people whose primary language is not English. Spanish versions of each form above are linked alongside the English PDFs. For additional language support, please call our office or see the Notice of Nondiscrimination for details on how to request an interpreter.