Forms

New Patient Forms

You may either print out your form and fill it out by hand or type directly onto the form below once you have selected “text”, then print and bring the form with you.  Due to HIPAA regulations, please do not fax any of these forms back to us.

Capital Women’s Care must receive permission from a child’s parent or legal guardian before providing treatments for an injury or illness that is non-life threatening. This form gives us legal permission to treat your child in case you cannot accompany them to the practice for treatment.

Note:

  • A parent/legal guardian must attend a minor’s first visit at Capital Women’s Care
  • A “Permission to Treat a Minor without a Parent/Guardian Present” form is required for a minor to be seen without his/her parent/legal guardian. 
  • In certain circumstances, in accordance with State and Federal laws, parent/guardian permission may not be needed for adolescents being seen for concerns of “heightened sensitivity” such as STD testing, family planning, mental health et cetera.

Medical Records Request

If you need a copy of your medical records please download the Medical Record Release Form below and fax or mail it to the office. You will need to personally sign this request.

Federal and State law requires the patient’s signature, or that of an authorized personal representative, to release or transfer medical records. The patient records are defined as all records that relate to the health of the patient and are prepared by or under supervision of a health care provider associated with Capital Women’s Care. We maintain the patient’s rights that all medical records are kept confidential according to all federal and state laws.

Please note that in some cases, a fee will be charged for medical record copies. The medical record department will be happy to provide you information about fees, expected turnaround times and other information related to your request.

Patients that provide records from another physician, outside of CWC, are encouraged to retain their own copy as Capital Women’s Care cannot provide a copy.

Please note:  We are not allowed by Maryland law to forward records from other physicians. We will charge for sending copies of your records in compliance with Maryland law. Allow 7-10 business days for processing medical records requests.

Notice of Privacy Policy

Work Leave Forms

Please submit your work leave forms to our Office Manager to be completed. As with medical records, please allow 7-10 days for completion. There is a $20 fee (payable by credit card, cash or check) for these forms to be completed.

Billing questions

Our billing is handled by a centralized facility for all of Capital Women’s Care.

Practice Management Partners: (800) 529-3489

Forms

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