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Patient Forms

Medical Records and Privacy

We are committed to protecting the privacy of your protected health information.  Our Notice of Privacy Practices serves to explain how we may use and disclose your health information according to the Health Information Portability and Accountability Act (HIPAA).

Virginia Code § 32.1-127.1:03 requires that most requests for copies of medical records must be made in writing.  Use the following forms to request copies of your medical records.

Medical Records Release Form (when requesting Hampton Family Practice to release information)

Medical Records Request Form (when requesting records from another party)

Living Wills and Advance Care Planning

If you are 18 or older, and mentally competent, then you have the right to make decisions about your medical care.  Advanced directives are legal forms that help you make decisions about you future medical care.

1. A living will (PDF) lets you state your wishes about medical care, or choose another person to make decisions for you if you lose the ability to do so.

2. A healthcare power of attorney(PDF) lets you name the person to make health care decisions for you if you become unable to decide for yourself.

3. An advance instruction for mental health treatment allows you to give instructions and preferences about mental health treatment.  You may select somone to make these decisions for you if you lose the ability to decide for yourself.  This document automatically expires in two years.

Registration Forms

Patient Registration/Patient Update Form

Past Medical History Form

Other Forms (Functional Medicine)

Functional Medicine Female Intake Form (Dr. Jennifer McCord/Jezeriah Cook, PA-C)

Functional Medicine Male Intake Form (Dr. Jennifer McCord/Jezeriah Cook, PA-C)