Forms
Patient Forms
Please select the appropriate packet to print and complete:
En Español
Por favor seleccione el paquete apropiado para imprimir y completar:
Consentimiento Informado por Telesalud
Medical Release Forms
To Tepeyac OB/GYN: Use this form to send your medical records to Tepeyac OB/GYN from another practice. (This form is for Tepeyac patients only.)
Current Patients with Tepeyac OB/GYN: Requests for copies of your medical records must be in writing, signed by you or your personal representative (that is, someone authorized by law to exercise rights on your behalf such as a parent of an unemancipated minor, the executor of an estate, a legal guardian, or anyone else empowered through a power of attorney or legal process to make health care decisions on your behalf) that clearly identifies to whom and where to send copies of the records and by what method. Records may be sent by mail, email, secure fax, or other agreed upon method. Copies may be picked up at Tepeyac’s office by you, your personal representative, or a person designated by you or your personal representative.
Use this form to release your medical records from Tepeyac directly to another practice or other third party. If you request an unsecure method of transmission, the security of your information is at risk.
Use this form to release your medical records from Tepeyac to you.
Use this form to designate a person to pick up your medical records at Tepeyac’s offices. Photo ID and a copy of the form must be presented at pickup.
Personal Representative of a Patient: Complete the appropriate patient form on behalf of the patient and submit documentation to verify your identity and authority to request and receive records on behalf of the patient
Please note: Tepeyac is unable to accommodate medical records release requests made verbally over the phone. The patient (or the patient’s personal representative) must request copies in writing, signed by the individual making the request. The patient (or the patient’s personal representative) may send us an electronic copy of a signed request (such as a PDF or scanned image), an electronically executed request with an electronic signature, submit a request on our secure patient portal, or they can fax or mail us a copy of a signed request. Allow 7-10 business days for turnaround of completed request forms.
TO THE PATIENT: If your records at Tepeyac are in electronic form, you may use the patient portal to access, print, and download them. To request copies of your paper or electronic medical records to be faxed, emailed, picked up at Tepeyac’s office, or transmitted through the patient portal, please complete and sign the appropriate record request form depending on whether the records are being released to you or to a third party (such as another provider or someone you designate). Tepeyac provides electronic copies of medical records at no charge. Electronic copies may be delivered via secure email, secure fax, patient portal transmission, or in-office pickup. If you request printed paper copies of your medical record, copying fees may apply consistent with Virginia law. Current rates are up to $0.50 per page for the first 50 pages and $0.25 per page for each additional page, in compliance with Virginia law. For large record requests, Tepeyac will notify you of the estimated copying cost based on the number of pages requested. Payment is required prior to preparation. If you request your electronic records on a flash drive or CD, Tepeyac may charge a flat fee of $6.50 inclusive of labor and supplies. Processing of record request forms typically takes 7–10 business days. If you or a designated third party will be picking up copies at Tepeyac’s office, we will contact you when the copies are ready. Copies will be held for 10 calendar days. If they are not picked up or alternate delivery arrangements are not confirmed within that time, the prepared copies will be securely destroyed.
TO THE PATIENT’S PERSONAL REPRESENTATIVE (for example, the parent of an unemancipated minor, a legal guardian, an executor, or a person holding a power of attorney or other legal authority to make health care decisions for the patient related to the records being requested): Please complete the appropriate patient form on behalf of the patient and provide a copy of your identification and authorization to act on behalf of the patient.
PICKUP BY DESIGNATED PERSON: A person designated by the patient or the patient’s personal representative to pick up copies at Tepeyac’s office will need to provide a photo ID and a copy of the form signed by the patient or personal representative designating that person to pick up the patient’s records.
Other Forms and Services
If you are filing a disability claim, please submit your forms directly to our office for completion.
Fees:
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$45.00 for completion of disability forms
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$45.00 for custom letters or administrative forms
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An additional $20.00 fee applies for requests requiring completion within 24 hours
Payment is required prior to processing.
Please allow 5–10 business days for completion unless a 24-hour rush request is submitted and paid.
Privacy Notice
All new patients need to read the Privacy Notice, sign the receipt, and return the receipt to the front desk at your initial visit. Established patients should review the Privacy Notice and sign an updated receipt annually or when the Notice is updated. You may sign the Privacy Notice electronically at Tepeyac’s Patient Portal when you register for secure messaging.
You may also be interested in optional forms mentioned in the Privacy Notice that you may obtain by clicking on the links below:
Divine Mercy Care may use limited patient information to contact you for fundraising purposes. You may opt-in/out of fundraising by completing this form.
You may request a list of disclosures made of your information, which were not for the purpose of your treatment, payment, or Tepeyac operations, and not otherwise made at your request. Please use this form to ask us to account for such disclosures.