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Policies & Forms

FairfaxMD uses an electronic health record (EHR) to accurately and efficiently record your medical issues. The actual record is transmitted securely to an encrypted server, safe from physical harm.

FairfaxMD Privacy Statement

Registration packet: 4 pages, a fillable PDF (portable document format) file. Please download and complete prior to your first office visit.

page 1: patient registration form
page 2: office policy
page 3: privacy policy
page 4: release of medical records (optional)

If you have problems opening this file, try one of the following:
Google Chrome web browser (Windows, macOS, Linux)
Firefox web browser (Windows, macOS, Linux)
Apple Preview (included with macOS)
Adobe Reader (Windows, macOS, Linux)

We here at FairfaxMD find it very helpful to have at least the last 2 years’ of notes, blood work and other test results. We kindly ask that you release your records to us, using the signed authorization form (page 5) above. You may sign this form while in the office, or fill and print the form prior to your visit.

If you don’t have a very thick medical chart, 2 years of all types of records should be sufficient. Please ask your doctor at your visit if more records are required.

Many area practices, including both Drs. Chen & Young’s former practices, have outsourced their medical records copying to Ciox Health (formerly Healthport). Ciox requires payment prior to release of records, with the following charges
per Virginia Code §8.01-413:

• Pages 1-50: 50¢ per page
• Pages 51+: 25¢ per page, no limit
• $10 search and handling fee, plus postage

Note: new rates take effect July 1, 2017:

Paper Records:
• Pages 1-50: 50¢ per page
• Pages 51+: 25¢ per page, no limit
• $20 search and handling fee, plus postage

Electronic Records:
• Pages 1-50: 37¢ per page
• Pages 51+: 18¢ per page, limit of $150
• $20 search and handling fee, plus postage

If you do not receive a bill from Ciox after 6 weeks, please let our office know as this means that records may not have been received. For billing inquiries, Ciox may be reached at 800 367-1500.