On line patient information portal

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.

Step 1 of 7

Registration Form

Click or drag a file to this area to upload.
List person/persons whom the Center (CHCNRV) may contact in the event you are not able to speak or in the event of an emergency.

You are required to provide photo identification and your insurance cards
Click or drag a file to this area to upload.
Click or drag a file to this area to upload.
Click or drag a file to this area to upload.
Click or drag a file to this area to upload.
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.
By providing an electronic signature in the box above, I am acknowledging that the above information is true and accurate to the best of my knowledge. I have had the opportunity to review the Notice of Privacy Practices and the No-Show Policy. I also attest that if it is found that I am knowingly withholding insurance information and the time frame to file previous claims has been exceeded, I will be held responsible for any past due amounts.