This notice describes how medical information about you may be used and disclosed and how you can get access to this information. This notice also reveals our policies and procedures regarding your financial obligations to the practice. Please review it carefully.

You must complete this form if this is your first visit to our practice or if you have not been to our practice within the last year.

You must complete this form if this is your first visit with Dr. Ashley McCowen.

You must complete this form if this is your first visit with our rheumatologist, Dr. Eric Kenny or our rheumatology physician assistant, Mark McGuire.

You must complete this form if you would like for us to release your medical records. Please fill out the form completely and mail, fax or bring it back to: Orthopaedic Center of Central Virginia 2405 Atherholt Road Lynchburg, Virginia 24501 FAX: (434) 485-8599 Failure to fill this form out completely will delay your request. Please note that we have up to 15 days from the receipt of your release form to process your request. The release forms are processed on a first come first serve basis only. We will mail medical records out to the mailing address that you provide on the attached form so please provide a complete mailing address. If you should have any questions, please do not hesitate to contact our office.