Below you will find six (6) forms used by Nova Urgent Care. If the receptionist mentions that you will need to complete the following forms, you can save time by completing the forms prior to your visit.

If possible, please fill out, print and fax the form to the appropriate facility prior to your visit. Or, bring the completed form with you at the time of your visit.

Ashburn Fax: 703.554.1110
Sterling Fax: 703.430.6985
Leesburg Fax: 703.777.1225
Warrenton Fax: 540.347.7622

Directions:

PDF Format
Please click on the link below to download the form (Adobe Acrobat Reader is required). Print out the form and fill out the information. Once the form is completed, print out the form and either fax it to the appropriate facility or bring it with you at the time of your visit.

HIPAA Authorization Form
(Release to Share Medical Information)
(PDF - 37 KB File)

Medical Records Release Form
(Release to Transfer Medical Records - fees apply)
(PDF - 33 KB File)

NOVA Urgent Care Patient Information Form
(PDF - 36 KB File)

Payment Extension Agreement
(PDF - 26 KB File)

Right to Privacy Notice and
Right to Privacy Acknowledgement
(PDF - 75 KB File / 37 KB File)

Word Format
Please click on the link below to open the file (Microsoft Word is required). If you receive a "password protection" box, please click on the "Cancel" button and the form
will appear. Complete the information on the form. Click on the "Tab" button to move through the form. Once the form is completed, print out the form and either fax it to the appropriate facility or bring it with you at the time of your visit.

HIPAA Authorization Form
(Release of Medical Information)
(Word Document- 37 KB File)

Medical Records Release Form
(Word Document- 86 KB File)

NOVA Urgent Care Patient Information Form
(Word Document- 114 KB File)

Payment Extension Agreement
(Word Document- 76 KB File)