Forms and Policies

Patient Forms:


  4. FAX FORMS TO 833-598-2055

If you do not have access to a fax machine or scanner, bring the forms with you to your appointment.

Privacy Policy



At Physicians To Women, we are committed to treating and using protected health information responsibly. This Notice of Health Information Practices describes the personal information we collect and how we use that information. It also describes your rights as they relate to your protected health information. This Notice is effective September 1, 2002 and applies to all protected health information as defined by federal regulations.

Understanding Your Health Record/Information

Each time you visit Physicians To Women, a record of your visit is made.  This record typically contains: patient symptoms, physical examination and test results, diagnoses, and a plan for care or treatment. This information, also referred to as your health or medical record, serves as a

  • basis for planning your care and treatment,
  • means of communication among the many health professionals who contribute to your care,
  • legal document describing the care you received,
  • means by which you or a third-party payer can verify that services billed were actually provided,
  • a source of data for medical research,
  • a source of information for public health officials,
  • a tool with which we can improve the care we render and the outcomes we achieve.

Your Health Information Rights

Although your health record is the physical properly of Physicians To Women, the information belongs to you. You have the right to: 

  • obtain a paper copy of this notice of information practices upon request,
  • inspect and copy your health record as provided for in 45 CFR 164.524,
  • amend your health record as provided in 45 CFR 164.528,
  • obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528,
  • request communications of your health information by alternative means or to alternative locations,
  • request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522,
  • revoke your authorization to use of disclose health information except to the extent that action has already been taken,
  • receive communication in a confidential manner.

(Fees may apply to cover the cost of copying, mailing, or other supplies associated with your request.)

Our Responsibilities

Physicians To Women is required to:

  • maintain the privacy of your health information,
  • provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you,
  • abide by the terms of this notice,
  • notify you if we are unable to agree to a requested restriction, 
  • accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We reserve the right to change our practices and to make the new provisions for all protected health information we maintain.  Should our information practices change, we will mail a revised notice to the address supplied to us for an individual patient.

We will not use or disclose health information without authorization, except as described in this notice.  We will also discontinue to use or disclose health information after we have received a written revocation of the authorization.

For More Information or to Report a Problem

If you have questions and would like additional information, you may contact Our office/practice manager at  (540) 982-8881.  

Examples of Disclosures for Treatment, Payment and Health Operations

We will use your health information for treatment.   Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of medical treatment.  

We will provide a subsequent physician or health care provider with your medical record should you need it.  A release of records will be signed prior to this transfer. 

We may use a sign-in sheet at the registration desk. We may also call you by name in the registration area when your physician is ready to see you or to complete the registration process.

We will use your health information for payment. A bill may be sent to you or a third-party payer.  The information on or accompanying the bill may include information that identifies you as well as your diagnosis, procedures, and supplies used.

We will use your health information for regular health operations.  Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it.  This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

Business associates:  There are some services provided in our organization through contacts with business associates. Examples include physician services in the emergency department, radiology, and certain laboratory tests. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Notification:   We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.  â€‹Physicians to Women may use and disclose medical information in order to contact patients for appointment reminders.  In leaving a message on an answering machine, Physicians to Women will only leave the name of the practice and the appointment time/date.  

Communication with family:   Health professionals may disclose relavent health information to any other person the patient chooses in her signed HIPPA form.

Research:   Patient information may be disclosed to researchers when such research has been approved by an institutional review board.   

Funeral directors:   Healh information may be disclosed to funeral directors consistent with applicable laws.

Organ procurement organizations:   Health information may be disclosed to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Fund raising:   We may contact you as part of a fund-raising effort.  

FDA:  We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

Workers compensation:   We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public health:   As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Correctional institution:   Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

Law enforcement:   We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

Federal law makes provisions for health information to be released to an appropriate health oversight agency or public health authority.   Other situations where this might apply include audits, investigations, inspections, licensure or disciplinary actions, and administrative proceedings.