Medical Records Release

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FCRS is proud to provide our patients and their physician’s copies of Medical Records when requested.

FCRS is dedicated to patient privacy and confidentiality, therefore we require a completed and signed authorization form to release records. Although we have attached our Medical Records Release Form below, FCRS will accept another provider’s authorization form-as long as it has been signed by patient/caregiver within 30 calendar days after receipt of such requests.

Please review the following policies regarding Medical Record Requests:

All Medical Record Requests will be reviewed and completed within 14 business days. Medical Records that will be going to another provider will not incur a fee.

Medical Records that will not be going to another provider will incur a $20.00 processing fee, plus a charge of $0.50/page for up to 50 pages, and $ .25/per page thereafter, as well as any postage and shipping costs. Payment must be made prior to your release of the copied records; we accept payment by phone with credit card, or payment may be made at the office with credit card, check or cash.

To Request Copies of Your Medical Records:

  1. Download and Print the Medical Records Request & Release Form
  2. Return completed and signed release to :

By Mail:

Fairfax Colon & Rectal Surgery, PC

Attn: Medical Records 2710 Prosperity Ave Ste 200

Fairfax, VA 22031


By Email:



By Fax:

(703) 712-8304

Attn: Medical Records