CONSENT FOR TREATMENT: I authorize the employees, agents and staff of the 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: 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.

TELEVISIT APPOINTMENT CONSENT: Televisit appointments involve 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 to conduct a health care appointment with me through a televisit appointment. I will be billed for this visit in the same way that I am billed for in office visits.

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: I authorize the Center to release all patient medical and billing information to any physician or healthcare entity involved in my care. This authorization includes treatment, billing, quality assurance, collections, litigation, and to any entity that is directly or indirectly responsible for payment to or review of services provided by the Center.

BILLING INFORMATION: I will provide the Center with complete and accurate information so that billing data can be appropriately submitted. The Center will make every effort to submit claims to insurance companies and promptly provide statements.

FINANCIAL RESPONSIBILITY: I am financially responsible for all charges, whether or not paid by insurance. The Center does not participate in every insurance plan. Payment is expected at the time of service. I understand that I am responsible for any deductibles, co-payments, and any applicable percentage of remaining charges.

CERTIFICATION AND ACKNOWLEDGMENT: 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).

CONSENT TO COMMUNICATION: I consent to be contacted by regular mail, text, by email or by telephone (including a cell phone number) regarding any matter related to my account.

Release of Information: List any person whom 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.

CONSENT TO TREAT: I grant permission for the Center to perform medical, behavioral health, and/or dental care on my child with or without my presence. This may include routine diagnostic and medical treatment that the attending providers or others of the health center medical staff consider necessary. Services could include treatment for illness or injury, including over the counter medications or necessary prescriptions, well child exams, appropriate immunizations, behavioral health evaluations, dental cleanings, x-rays, fluoride treatments, sealants, and limited restorative dental treatments. Attempts will be made to notify the parent/guardian of the minor’s appointment and to see if they wish to attend the visit. If no contact is made and all consents are in place, the Center will continue the appointment as needed and attempt contact the parent with follow-up information following the appointment including sending home a copy of the care summary.

AUTHORIZATION FOR EXCHANGE OF HEALTH INFORMATION: I hereby authorize Community Health Center of the New River Valley’s School Program to exchange health records with the appropriate school district for the purpose of providing care and treatment.

INFORMED CONSENT FOR GENERAL OR REMOTE SUPERVISION: I understand that the records for services provided by the dental hygienist will be reviewed by a Virginia licensed dentist providing the hygienist general supervision. I understand that treatment I receive from the dental hygienist is limited in scope and that it does not take the place of a regular dental examination or treatment by a licensed dentist. I understand that the dental hygienist may refer to a dentist or other specialist for further treatment when a dental condition requires more treatment that the dental hygienist can provide.

By signing below, I agree that I have provided accurate answers. I have reviewed the acknowledgements and authorizations and agree to adhere to the requirements as written. I have reviewed the Notice of Privacy Practices. My signature demonstrates consent and acknowledgement of all patient responsibilities and rights as outlined in this patient registration packet. It is my responsibility as a patient to contact the previous provider’s office to transfer medical records. I can ask for a copy of my medical records at any time.