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Patient Forms

Below are common forms you may need at Sentara Martha Jefferson Hospital. If you have questions about forms, please talk to your healthcare provider.

Forms You May Need

Advance Medical Directive

Sentara Healthcare and the Sentara Center for Healthcare Ethics are offering the community the opportunity to complete their Advance Care Plan (Advance Directive) and register it, free of charge, with our national Advance Directive Registry through the U.S. Living Will Registry. Where ever you go in the United States your Advance Care Plan will be accessible by healthcare professionals when needed to guide your medical care if you are unable to communicate your wishes or make your own decisions.

Authorization for Release of Medical Information

You will need this to submit this form to request paper medical records.

Sentara Medical Group New Patient Form

You will need this form to give authorization to release or exchange incoming medical records.

Sentara Martha Jefferson Medical Group Authorization to Disclose Protected Health Information

If you want to have a medical record transferred from another doctor’s office to your new Sentara Martha Jefferson Medical Group office, please complete this form. Likewise, this form can also be used to authorize someone other than you to have access to information about your healthcare status on treatment. Just print and complete the form and bring it with you to your next appointment.

Consent for Treatment & Financial Agreement

To review a copy of the Sentara Hospitals and Sentara Martha Jefferson Medical Group Consent for Treatment & Financial Agreement details. (Note: Must be completed and signed in-person. Do not print).

Additional Forms

In an effort to make your appointment check-in process smoother and more efficient, here you can find a number of forms that you may fill out in advance of your appointment.

 

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