Medical Records Request leaving VAPG

In order to proceed with obtaining the medical records, we need your assistance in filling out the attached Medical Records Request Form. This form is necessary to authorize the release of the medical information and ensure the safety of the records being transferred.

If any court order or legal request is available, Please attach to the return email instead of the request form.

Please be aware this process takes up to 15 business days once all information and payment is received. There is a fee for Medical Records Request. Please also be aware of any outstanding bills are due immediately with a forwarding address.

Medical Records Request leaving VAPG Form

Download and Complete the Form: Please find the Medical Records Request Form. Fill out all required fields, including your contact information, the records you are requesting, and your preferred delivery method.
Sign and Date the Form: Make sure to sign and date the form, where indicated to authorize the release of the records as per HIPPA compliance.
Return the Form: Once completed, please return the form to us by emailing it to forms@vapg.com, faxing it to us at 703-280-9350, or using the patient portal
Once form has been received, a member of our staff will contact you to collect payment or please call our front desk to submit payment. Please be aware, this process will not start until all information is received with payment.

There is a fee for patient medical charts are for the cost of supplies for and labor of copying, as well as storage for the requested information. Postage will be charged on an individual basis. Outstanding bills are due immediately with a forwarding address. Non-reconciled accounts are subject to collections 30-days following records transfer. Records requests are handled pursuant to federal and state regulations, including Virginia code 32.1-127.1:03

Virginia Pediatric Group