On line patient information portal - Community Health Center of NRV

Thank you for visiting Community Health Center of the New River Valley. To read our welcome message from our patient intake forms, click here.

For your convenience, we have implemented an on-line patient registration process. You may be asked to physically sign some forms upon entering the Center, but completing this form will significantly speed your process. It is the same form you would physically fill out at our office. The average time to complete the form is about 15 minutes.

If you would prefer to download and print an application and complete it at home, you may do so by clicking here.

Due to increased patient volume, we are temporarily not accepting new medical or dental patients as we add more clinical providers to our CHC family. We hope to begin enrolling new patients before the end of 2022. You can still complete a new patient packet as we will hold your information until we can register you. We wholeheartedly apologize for the inconvenience.

Please be advised that we are NOT a COVID Testing Facility. This form should only be filled out to establish care with our clinic.

– Step 1 of 12

Registration Form

Name *

First

Middle

Last

Date of Birth *

Social Security Number *

Preferred Location *

Christiansburg
Giles (Pearisburg)
Radford/Pulaski (Dublin)

Primary reason for contacting us

Medical
Dental
Behavioral Health

How did you hear about CHCNRV? *

Demographics

Nickname/Preferred Name

Mailing Address *

City / State / Zip *

Is your street address the same as your mailing address? *

Street Address *

Street City / State / Zip *

Primary phone (the phone number you use most) *

Phone type

Home
Cellular
Work

Secondary Phone

Phone type

Home
Cellular
Work

Preferred Method of Contact

Home Phone
Cell Phone
Text
Email

Parent / Legal Guardian if under 18

Sex *

Male
Female
Other

Marital Status

Divorced
Married
Single
Partner
Legally Separated
Widowed

Employment Status

Employed Full-time
Employed Part-time
Self-employed
Retired
Active Military Duty
Reserved for National Assignment
Not employed
Other

Employer Name

Are you a student?

Email Address *

Emergency Contact Name

First

Last

Relationship

Phone Number (note: Emergency Contact number must be different from your primary contact number)

Address

City / State / Zip

Race (check all that apply)

African-American
Asian
White
Native American
Pacific Islander
Other

Ethnicity

Hispanic
Non-Hispanic

What is your primary language *

Do you require a translator? *

Are you a United States Military Veteran

Are you a

US Citizen
US Resident
Other

Sexual Orientation

Straight (not lesbian or gay)
Lesbian / Gay
Bisexual
Something else
Don’t know
Choose not to disclose

Gender Identity

Male
Female
Transgender Male / Female-to-Male
Transgender Female / Male-to-Female
Other
Choose not to disclose

Insurance Information

Do you have Health Insurance? *

Do you have a Payee for your insurance? *

Another person or organization that has agreed to pay for your visit with us.

Payees Name *

Payee's Phone Number *

Payee's address

Upload Approval to Pay

Click or drag a file to this area to upload.

Please upload a copy of the approval to pay for services from your payee. Proof from your payee is required prior to your appointment being made. If your payee would like to send the letter directly to our office, our contact information is below. Fax: 540-394-4033 Email: applications@chcnrv.org

You are required to provide photo identification and your insurance cards

Primary Insurance Company Name *

Subscriber/Policy/Medicaid/Medicaid Number *

Group Number

Policy Holder Name *

Policy Holder Date of Birth *

Relationship to the patient *

Policy Holder address

Please upload a copy of your photo ID

Click or drag a file to this area to upload.

Please upload a copy of the front of your insurance card

Click or drag a file to this area to upload.

Please upload a copy or photo of the back of your insurance card

Click or drag a file to this area to upload.

Is there another insurance? *

Secondary Insurance Company Name *

Subscriber / Policy / Medicare / Medicaid number *

Group Number *

Secondary Policy Holder Number *

Secondary Policy Holder Date of Birth *

Relationship to Patient *

Policy Holder Address *

If you have and additional insurance card, please upload a copy or photo of the front here

Click or drag a file to this area to upload.

If you have and additional insurance card, please upload a copy or photo of the back here

Click or drag a file to this area to upload.

No Insurance Coverage *

Initial in the box if the following is true: I currently do not have any medical insurance or pharmacy prescription coverage, whether through the government (Medicare or Medicaid), employment, or a private company. When I receive insurance coverage or pharmacy prescription coverage, I will notify the Community Health Center within 30 days of the start date of the new insurance and will provide a copy of my card.

Would you like to apply for our Sliding Fee Discount Program? *

Decline Sliding Scale *

Initial in the box if the following is true: I understand that without having insurance and not applying for the Sliding Fee Discount Program, I will be responsible for my visits. I will be required to pay for my visits upfront, in full. If I have insurance, I will be responsible for any balance due after my insurance has been processed.”

Discount Fee Program Application

How many people are in your family? *

Please list them below, with the required information for each.

1. Self *

(Your name goes here, First, Last)

SSN *

Date of Birth *

Relation *

MGI *

Monthly Gross Income

Employer name

(if employed)

2. Family member

SSN

Date of Birth

Relation

MGI

Monthly Gross Income

Employer name

(if employed)

3. Family member

SSN

Date of Birth

Relation

MGI

Monthly Gross Income

Employer name

(if employed)

4. Family member

SSN

Relation

Date of Birth

MGI

Monthly Gross Income

Employer name

(if employed)

5. Family member

SSN

Date of Birth

Relation

MGI

Monthly Gross Income

Employer name

(if employed)

6. Family member

SSN

Date of Birth

Relation

MGI

Monthly Gross Income

Employer

(if employed)

*If someone can claim you as a dependent on their taxes, then list all other family members on that tax return. Document and provide proof of all income received: Paycheck stubs, Retirement, Social Security, Pension, Disability, Worker’s Compensation, Unemployment, Child Support, and ALL others not listed.

Application will be rejected if documentation is not provided.

Employer and Income Information

Employer Name

Employer Phone Number

Date employment began

Employment type

Full Time
Part Time

How often are you paid?

Weekly
Bi-weekly
Monthly
Bi-monthly
Other:

If other, how often? *

Amount you are paid before taxes:

Did your household file income tax last year?

How did you file?

Joint
Single

Unemployment and Disability Information

If unemployed, what was the date your employment ended?

Does anyone receive unemployment wages?

If yes, how much?

If Unemployed, has anyone applied for Disability?

Is anyone in your family planning on applying for disability? This includes you.

Government Assistance and Insurance Information

Do you or anyone in your household have Medicaid?

If yes, who? *

Do you/spouse or any children under 18 receive Social Security Benefits?

Do you or others in the family have insurance?

If yes, name of Insurance *

Personal Information

In order to qualify for the Discount Fee Program, you are required to provide proof of identification and ALL income that has been received in your household. Examples of income include: Paycheck stubs for most recent full month of work, Social Security Letter, SNAP/WIC Benefits Letter, Self -Employment Documentation (Taxes are Recommended), Letter from Employer on Company Letterhead, Retirement/Pension, Documentation of income from any other source. Please upload proof of income below or email applications@chcnrv.org

Submit a copy, photo or scan of your Proof of Income here.

Click or drag a file to this area to upload.

Submit a copy, photo or scan of your Proof of Income here.

Click or drag a file to this area to upload.

Submit a copy, photo or scan of your Proof of Income here.

Click or drag a file to this area to upload.

Submit a copy, photo or scan of your Proof of Income here.

Click or drag a file to this area to upload.

Submit a copy, photo or scan of your Proof of Income here.

Click or drag a file to this area to upload.

Initials *

Initial Here

CERTIFICATION AND ACKNOWLEDGEMENT

I certify that all of the above information and all information supplied by me, as part of the registration process, is correct. I also acknowledge receipt of the Community Health Center’s Notice of Privacy Practices (HIPAA) and Part 2 Practices as applicable.

Signature *

Relationship to Patient *

Date *

HIPAA Release of Information

List any person who we can talk to about your medical conditions (Protected Health Information) and your appointments. This excludes Behavioral Health and Substance Abuse conditions (Sensitive Protected Health Information), a separate release of information will need to be signed to discuss these with other individuals.

I do not want my medical conditions discussed with anyone.

Please be aware that checking this box means that we will not be able to discuss your medical conditions with anyone. Please sign and date below if you agree. No other fields on this form will need to be completed. If you would like your medical conditions discussed with someone else, please uncheck the box above and provide their information below.

Name

First

Last

Phone

Relationship

Name

First

Last

Phone

Relationship

Name

First

Last

Phone

Relationship

Signature of patient for HIPAA release (or parent or guardian if patient is under 18) *

By signing, I agree that I have provided true answers to the best of my knowledge. It is my responsibility, as the patient, to contact previous provider’s offices for transfer of medical records. I have the ability to ask for a copy of my medical records at any time from CHCNRV. I have reviewed the Notice of Privacy Practices (HIPAA).

Date *

Consent for Minor and/or Adult with Guardian

Consent for treatment when Parent/Legal Guardian is not physically with Minor/Adult with Guardian

Not applicable

Name of Minor/Adult with Guardian

Date of Birth of Guardian

I (we) appoint (Proxy Decision Maker Name)

and/or (Proxy Decision Maker Name)

Who is the (Proxy Decision Maker Name) patient‘s (Relationship to Minor/Adult with Guardian)

as my (our) proxy (Relationship to Minor/Adult with Guardian) (Relationship to Minor/Adult with Guardian) decision maker for consenting to nonurgent medical care for my (our) minor/adult with guardian listed above. I (we) have the legal right to delegate such consent to the proxy decision maker, who is an adult and legally and medically competent to exercise the authority so delegated. Be advised that protected health information may be shared with the proxy to facilitate informed decision making.

IN WITNESS WHEREOF, the undersigned have executed this instrument as the day of (signature / date)

Parent or Legal Guardian Name

Parent or Legal Guardian Signature

Driver’s License Number of Proxy Decision Maker

Health History

General Health

Name of Pharmacy

Phone number of Pharmacy

Why did you make this appointment?

Regular checkup
First appointment to start care with new doctor
Switching doctors
Have a specific health problem

If you have a specific health issue, please explain

If you are switching doctors, from whom?

Are you taking any prescription medicines?

If yes, list name of medication, amount/pill size, how many doses you take and what time of day.

What over-the-counter medicines (medicine you do not need a prescription for) do you take regularly?

Pain Reliever (example: Tylenol, Advil, Asprin)
Vitamins
Antacid (example: Tums, Prilosec)
Herbal Medicine (Fish oil, Ginseng)
Other

Please list any vitamins, herbal supplements or other that you take.

Do you get an allergic reaction (bad effect) from any of the following? (Check all that apply)

No – I have no allergies that I know of
latex (rubber gloves)
Grass or pollen
Eggs
Shellfish
Other (please list)
Medicines (please describe)

Allergies to medicines

If you have a known allergy to any medicine or medicines please list them and describe the effects.

If you have other allergies, please list them

Have you ever been in the hospital overnight?

If yes, list the reason why and when you were in the hospital. Please list all hospital overnight stays.

Have you ever had a colonoscopy (a test to look at your insides by sending a camera through your bottom)

If you have had a colonoscopy, when and where?

When was your last tetanus shot?

When was your last pneumonia shot?

When was your last flu shot?

If the patient is a minor, are they up to date on their vaccinations?

If yes, can you provide a copy of the minor's immunization record? If not, please explain why.

Do you smoke cigarettes, cigars, use snuff, chew tobacco or vape?

If yes, when did you start and how much per week?

Do you drink alcohol?

If yes, how many drinks do you have in a typical week?

Do you use anything to help you walk?

If so, what do you use?

Check any of the following types of help at home your receive (paid help or family and friends)

Cleaning/laundry
Shopping
Personal Care
Taking Medications
None

In the past year do you feel you have been emotionally or physically abused?

Have you ever had any of the following? (check all that apply)

Anemia (low iron blood)
Heart trouble
Hepatitis (Yellow jaundice)
Rheumatic fever
High blood pressure
Epilepsy (fits, seizures)
Sexually Transmitted Disease (STD, STI)
Asthma (wheezing)
Hemorrhoids (piles)
Tuberculosis (TB)
Ulcers
Skin problems
Anxiety (nerves, panic attacks)
Diabetes (sugar)
Cancer
Pneumonia
Stroke
Depression
Other

If you have experienced other medical conditions, please list them here

For Women Only

Have you ever been or are you currently pregnant?

If yes, how many times?

How many children have you given birth to?

Do you use birth control (the pill, condoms, intrauterine device, Nexplanon)?

If yes, which kind?

Have you had a PAP smear in the last year? If so, what doctor?

Were there any abnormalities in your PAP smear? If so, what?

Have you had a mammogram (breast x-ray)?

What was the date of you last mammogram and where?

Dental Health History

We offer affordable health care and dental care through the use of a Discount Fee Program to all patients at or below 200% of the poverty level. All patients are eligible to apply for the Discount Fee Program. To apply for the Discount Fee Program, please complete the Discount Fee Program Application. A link to the application is available on the front page or our website at www.chcnrv.org.

Name

First

Last

Today's Date

Age

Sex

Male
Female

When was your last dental visit?

Do you brush daily?

How many times per day?

Do you floss daily?

How many times daily?

Do you have a specific dental concern or problem?

How would you rate your current dental health?

Good
Fair
Poor

Are you currently in discomfort?

Have you been to the ER in the last year for dental issues?

If yes, how many times?

Do you have Osteoporosis?

Do you have a history of taking Bisphosphonates? (Bisphosphonates are prescription drugs that are commonly used to treat Osteoporosis, like Boniva or Fosamax)

Do you require antibiotic pre-medication prior to dental work?

Do you have food sensitivity to:

Heat
Cold
Sweets
Discomfort when biting

No Show Policy

Patients are responsible for keeping scheduled appointments and for contacting the office to cancel or reschedule their appointment. Last minute cancellations and no-shows limit access to other patients needing care. We require notification of cancellations or reschedules at least 24 hours prior to the appointment. Failing to keep your first appointment as a new patient with our center will result in you being placed in a “Sit and Wait” status. “Sit and Wait” status means you will not be given another scheduled appointment but will be required to call the office for a same-day appointment.

To avoid this, please make sure to call the office at least 24 hours prior to your appointment if you need to cancel or reschedule.

You must sign below to acknowledge your understanding of our No-Show policy.

Signature *

Date *

Welcome! We are so honored that you have chosen the Community Health Center of the New River Valley to be your new healthcare home.

Here at the Community Health Center, we value a complete approach to patient care, made possible through accessible and high-quality health care services for all.

We feel strongly that in order to help you feel your best, it is important that we treat both your body and mind through an ‘integrated care’ model.

What is integrated care?

-Integrated care means that you will have a team of primary care and behavioral health providers working together with you to provide your care.

Who is on my integrated care team?,

-Your medical provider (doctor or nurse practitioner)

-Your nurses/

-Your behavioral health provider

-Your care coordinator as needed

What is the benefit of integrated care?

-Opportunity to discuss mental health and/or substance misuse conditions like nicotine, alcohol or drugs.

-Opportunity to focus on health behaviors like how you eat, exercise and sleep.These discussions will include how these activities contribute to medical illnesses and stress-related physical symptoms.

-Behavioral Health Consultation (BHC) services can help you reduce symptoms associated with many different long-term medical conditions including headaches, sleep problems, high blood pressure, asthma, diabetes, obesity, chronic pain, and irritable bowel syndrome.

At your initial visit, and because we strongly believe in the importance of treating you as a complete and total person, you will meet with both the medical provider and the behavioral health specialist for an assessment. You and your care team will then work together to decide the best plan moving forward in order to help you meet your personal health and wellness goals.

Finally, thank you for entrusting us with your care. We are excited to welcome you into the CHC community, and we look forward to meeting you at your appointment!

Sincerely,

The CHCNRV team

Signature *
By signing above, I agree with the care plan outlined above. I understand that I will be meeting with both the medical provider (physician or nurse practitioner) and the behavioral health provider at my first visit at the Community Health Center.

Click the Submit button below to submit your information.

Please allow 24 hours for processing of your application.