Patient Forms and Notices

Virginia - NSA Form Disclosure.pdf

Medical History Form

RIV Financial Policy Agreement Form

Nondiscrimination Policy Form

HIPAA Release Form

Notice of Privacy Practices

Medical Records Release Authorization Form

Good Faith Estimate Notice/No Surprises Act

No Surprises Act Disclosure

Registration Form - Spanish

Notice of Privacy Practices - Spanish

Nondiscrimination Policy Form - Spanish

Medical Records Release Authorization Form - Spanish

Consistent with state and federal privacy laws, and as a condition of treatment, audio or video recordings are not permitted inside Retina Institute of Virginia facilities. Should anyone be observed recording or taking photographs with a cellphone or other device, the individual will be asked to immediately erase the audio, video, or photograph to protect the privacy of other patients and RIV associates.