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Please complete this form to become a patient. Your information is secure and held in confidence on a third-party server in accordance with HIPAA standards.

Step 1 of 5

Do you have Health Insurance? *

Do you have a Payee for your visit? *

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

Acknowledgments and Authorization form

CONSENT FOR TREATMENT

Initials *

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CONSENT FOR TREATMENT

I authorize the employees, agents and staff of the Community Health Center to perform and hereby consent to such medical treatment and examinations, including diagnostic procedures or behavioral health evaluations, as may in the opinion of the patient’s physician be necessary.

INFORMED CONSENT FOR INTEGRATED CARE SERVICES

Initials *

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INFORMED CONSENT FOR INTEGRATED CARE SERVICES

I understand that my provider works within a multi-disciplinary team, collaborating with social workers, care coordinators, and case managers as appropriate in order to ensure that my health care needs are most appropriately met. I understand that my integrated care team will regularly discuss my care and all team members have access to my protected health information (PHI) including, but not limited to, behavioral health/substance use disorder diagnoses and progress notes. I understand that all information regarding services is confidential and will not be released to any other agency or individual without my knowledge and consent, except when required by law (such as abuse and/or neglect of a person who is presently a minor or elderly, and/or serious intent of harm to self or others).

TELEVISIT APPOINTMENT CONSENT

Initials (copy) *

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TELEVISIT APPOINTMENT CONSENT

I understand that a TeleVisit appointment involves the use of electronic devices such as a computer, tablet, smart phone or telephone to enable two-way communication between the patient and their provider at different locations for the purpose of diagnosis, treatment, therapy, follow-up and /or education. I consent for my medical, dental, and/or behavioral health provider at the Community Health Center of the New River Valley to conduct a health care appointment with me through a TeleVisit appointment. I understand that the laws that protect privacy and the confidentiality of my medical information also apply to TeleVisits. I understand that my insurance carrier will have access to my medical records for quality review/audit as they would with an in-person office visit. I understand that I will be responsible for any copayments, deductibles or coinsurances that apply to my TeleVisit appointment. I understand that I have the right to withhold or withdraw

NO GUARANTEE

INITIALS *

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NO GUARANTEE

I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made as to the result of any procedures, treatments or examinations.

RELEASE OF INFORMATION

INITIALS *

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RELEASE OF INFORMATION

I authorize the center to release any and all patient medical and billing information to any physician involved in my treatment; to any healthcare facility to which I/the patient is discharged or transferred to for treatment, billing, quality assurance, collection, or defense of litigation or anticipated litigation; and to any insurance company, review organization or other entity, which is directly or indirectly responsible for payment or review of services provided by the Community Health Center. I consent to the use and/or disclosure of my protected health information to carry out treatment, payment or healthcare operations by the Community Health Center.

DEEMED CONSENT FOR BLOOD TESTING

INITIALS *

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DEEMED CONSENT FOR BLOOD TESTING

I understand that under Virginia Law, if a healthcare provider, a person employed by, under the direction of, or control of a healthcare provider, is directly exposed to body fluids of a patient, which may transmit viruses causing HIV or Hepatitis B or C, the patient will be deemed to have consent for testing for HIV or Hepatitis B or C, and to the release of such test results to the person who was exposed. (Exposure could occur due to an accidental needle stick.) A patient who tests positive will be afforded the opportunity for individual face-to-face disclosure of test results and appropriate counseling.

BILLING INFORMATION

INITIALS *

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BILLING INFORMATION

It is important that you provide us with complete and accurate information (i.e. home address, phone numbers) so that we may properly submit billing data to your insurance company. We will make every effort to submit claims to your insurance company and promptly provide you with our statements. However, if for any reason the statement is returned to our office because of a problem with an address you provided, we will call you to secure full payment. Please ensure that all of your information is accurate and up-to-date.

FINANCIAL RESPONSIBILITY/MEDICARE/MEDICAID

INITIALS *

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FINANCIAL RESPONSIBILITY/MEDICARE/MEDICAID

I understand that I am financially responsible for all charges, whether or not paid by insurance. The Community Health Center does not participate in EVERY insurance plan. I understand that I am responsible for verifying that the Community Health Center provider is a participating provider in my insurance plan. Patients’ are responsible for understanding benefits. Payment is expected at the time of service. I understand that I/the patient am responsible for any deductibles, co-payments and any applicable percentage of remaining charges.

DISCOUNT FEE PROGRAM

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DISCOUNT FEE PROGRAM

Qualifying for our discount fee program based on your family income and family size may result in lower charges. You are required to report any income and family size changes to us as this may impact the amount you are expected to pay. We will review and update your information annually. Eligibility cannot be determined until we receive all requested information. If it is determined you are not eligible for the discount fee program and you have incurred charges, you will be expected to pay the balance due. We will assist you by arranging a payment plan if needed.

CERTIFICATION AND ACKNOWLEDGEMENT

INITIALS *

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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.

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

Name

Demographics

Insurance Information

Discount Fee Program Application

Employment Information

Income Information

Unemployment Information

Disability Information

Government Assistance Information

Insurance Information

Personal Information

In order to qualify for the Discount Free Program, you are required to provide several pieces of information and ALL income that is received in your household. Please upload proof of income below or mail to applications@chcnrv.org.

Acknowledgments and Authorization form

CONSENT FOR TREATMENT

INFORMED CONSENT FOR INTEGRATED CARE SERVICES

TELEVISIT APPOINTMENT CONSENT

NO GUARANTEE

RELEASE OF INFORMATION

DEEMED CONSENT FOR BLOOD TESTING

BILLING INFORMATION

FINANCIAL RESPONSIBILITY/MEDICARE/MEDICAID

DISCOUNT FEE PROGRAM

CERTIFICATION AND ACKNOWLEDGEMENT

HIPAA Release of Information

Consent for Minor and/or Adult with Guardian

Please allow 24 hours for processing of your application.