Patient Forms
Forms & policies.
Download the latest patient forms directly from Privia Medical Group. Most can also be completed online through the patient portal.
Required forms & notices
Notice of Privacy Practices
How your health information may be used and disclosed, and how you can access it.
Authorization for Release of Medical Information
Authorize the disclosure of your health information to a designated person, company, or facility.
Authorization & Consent for Treatment
Required consent for treatment, communications (calls, emails, texts), and financial responsibility.
Patient Designated Contacts
Optional — designate the people we may share your health information with.
Informed Consent for Telehealth Services
Process for documenting and transmitting information using virtual visit technology.
Health Information Exchange (HIE) Opt-Out
Opt out of sharing your protected health information through the Privia HIE network.
Financial Policy
Your financial responsibility for medical services regardless of insurance eligibility or coverage.
SimplyCare office forms
For your convenience, complete these before your visit.
Authorization to Release Healthcare Information
Release of records to or from another provider.
Language Services: SimplyCare and Privia Medical Group provide free language assistance services to people whose primary language is not English. See the Notice of Nondiscrimination for details.