Galax New Patient Registration

Patient Registration

Neighbors Caring for Neighbors
Patient Information
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email
example@example.com
Birth Date

MonthDayYear
Sex at birth

MaleFemale
Social Security Number
Single

SingleMarriedDivorcedWidowed
Employed

EmployedUnemployedDisabledRetiredStudent
Current Employer
Employer Phone Number
Please enter a valid phone number.
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Responsible Party Information
Responsible Party

YourselfSpouseParentOther
Name

First NameLast Name
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Birth Date

MonthDayYear
Minors: (Please complete this section only if the patient is under 18)
Please list other parent/guardian if applicable
Is the child in foster care? If yes, please ask for the Foster Care Form.

YesNo
Insurance Information
Name of Insurance
Name of Policyholder
Relationship to Patient
Policy ID Number
Policyholder Birth Date

MonthDayYear
Type of Insurance

MedicareMedicaidOther
Is there a secondary insurance?

YesNo
If yes, please list:
Emergency Contact
Emergency Contact Other Than Spouse
Relationship to You
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Pharmacy Information
Preferred Pharmacy
City
Preferred Pharmacy Phone
Please enter a valid phone number.
The following information is for public health service grant purposes only. No personally idenifiable information is ever reported. By providing this information, you help us continue to receive funding to provide services to the community and special populations. Please select ansers below. Thank you.
Marital Status

MarriedSingleWidowedOtherOther
Race (If more than one, check all that apply)

American Indian or Native AlaskanBlack or African AmericanAsian IndianChineseFilipinoJapaneseKoreanVietnameseOther AsianNative HawiianOther Pacific IslanderGuamanian or ChamorroSamoanWhiteMore than one raceUnreported/Choose not to disclose race
Your Ethnicity

Hispanic or LatinoNot Hispanic, Latino or SpanishMexican, Mexican American, Chicano/oPuerto RicanCubanAnother Hispanic, Latina/a or Spanish origin
Preferred Language

EnglishSpanishOther
Is an Interpreter needed?

YesNo
Are you a veteran?

YesNo
Do you move to differnt locations to work on a farm or in agriculture?

YesNo
Are you homeless?

YesNo
If yes, where do you sleep at night?

ShelterStreetWith a friendOther
Number of people in your household
Annual household income (please circle one)

$0 - $10,000$10,000 - $14,999$15,000 - $19,999$20,000 - $24,999$25,000 - $29,999$30,000 - $34.999$35,000 - $39,999$40,000 - $49,999$50,000 - $59,999$60,000 - $69,999$70,000 - $79,999$80,000 - aboveChoose not to disclose
Where did you hear about Tri-Area Community Health?

CollegeCommunity EventFamily/FriendHealth Department/DSSNewspaperWebsite/Social MediaOther
AUTHORIZATIONS AND CERTIFICATIONS

I HEREBY AUTHORIZE THE FOLLOWING:

Tri-Area Community Health through its appropriate personnel and/or its medical staff to perform, administer, prescribe, or to have performed, administered, or prescribed upon, to, or for me or any members of my family (including minor children) whose names appear below, such examination, tests, immunizations, injections, and diagnostic procedures as are deemed necessary. I also certify that all information contained herein is true and correct to the best of my knowledge and belief, and that no facts have been omitted.

Insurance Authorization and Assignment to furnish information to insurance carriers concerning my illness and treatments, and I hereby assign to the physician(s) all payments for medical services rendered to myself and my dependents. I understand that I am responsible for any amount not covered by insurance.

Medicare Lifetime Authorization for physical services and request that payment of authorized Medicare benefits to make either to me or on my behalf to Tri-Area Community Health, Inc., d.b.a. Tri-Area Community Health, for any services furnished to me by their physicians. I authorize my holder of medical information about me to release to the health care financing administration and its agents any information needed to determine these benefits or the benefits payable for related services.

Rights of Minors: Parents generally have the right to access their minor child’s health records. However, Virginia laws gives minors additional privacy rights for records related to behavioral and reproductive health care services, including services related to mental health, birth control, pregnancy, and family planning. Your minor child may have rights to seek care and restrict access to their medical records for these types of services.

School Based Program: Please complete the School Based Health Center Consent Form which provides additional information for the treatment of your child.

Deemed Consent for Designated Blood-borne Pathogetns: In the event that TACH staff comes in contact with my or my children's body fluids, I consent to be tested for HIV, Hepatitis B and C.

I ALSO CERTIFY that I have read and understand the collection policy of Tri-Area Community Health and agree to abide by it.

I ALSO CERTIFY that I have read and understand the No Show Policy of Tri-Area Community Health and agree to abide by it.

i ALSO CERTIFY that I understand that LEgal Fees for Court Appearances for Providers of Tri-Area Community Health are in place and the fee schedule can be obtained upon request.

I ALSO CERTIFY that I understand that abuse against staff or other patietns will not be tolerated. This included physical assault, threats, verbal harassment or cursing, or sexual language or unwanted touching. Violators may be permanently dismissed from our practice.

THE INFORMATION PROVIDED ON THIS REGISTRATION FORM IS TRUE, ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
Signature

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Date

MonthDayYear
Date
Authorization for Permission to Discuss Protected Health Information
Name

First NameLast Name
Birth Date

MonthDayYear
I hereby give my permission to the person(s) listed below to receive information about my care.
Signature

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Date

MonthDayYear
Date
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Signature

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Date

MonthDayYear
Date
Relationship to Patient
Patient Acknowledgement of Receipt of Notice of Privacy Practices
Name

First NameLast Name
I acknowledge that the Tri-Area Community Health’s Notice of Privacy Practices is available on the website at www.triareahealth.org, or from any Tri-Area Community Health Office.
Signature

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Date

MonthDayYear
Date
School Based Health Center Consent Form
Student Name

First NameLast Name
Birth Date

MonthDayYear
Social Security Number
School
Grade
Medical Care

Services Provided
- Physical Exams for school, sports & camp
- Treatment for acute and chronic illness and injuries
- Vision/hearing screenings and follow-up
- Referrals for specialty services
- Basic laboratory services and test
Services Provided
- Talk Therapy to address mental health concerns
- Tools for improved emotional regulation, coping skills, and social skills
- Referrals for specialty services
I consent for my child to receive medical care through the School Based Health Center.
Does your child have health insurance?

YesNo
Insurance Name
Policy Number
Person Insured
Where do you take your child to the doctor?
Provider Phone Number
Please enter a valid phone number.
Last Appointment Date

MonthDayYear
Date
List all allergies to medications, food, bee stings, etc...
Does your child require an epi-pen?
List all current medications, dosage, and time taken.
What pharmacy do you use?
Does your child have any medical problems including learning or physical disabilities? If so, please list.
Does your child's parents or sibling have any medical problems? If so, please list.
Has your child ever had any surgeries? If yes, please describe.
What language is most often spoken in your home?
Is there any other important health information we should know?
Would you like to request any other assistance, or have any comments that might help the health center serve you better?
May we leave a voice message with NEGATIVE test results?

YesNo
Parent or Gardian Information
Mother/Guardian Name
Birth Date

MonthDayYear
Home/Work Phone #
Please enter a valid phone number.
Father/Guardian Name
Birth Date

MonthDayYear
Home/Work Phone #
Please enter a valid phone number.
Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Emergency Contact
Relationship
Phone Number
Please enter a valid phone number.
Authorization for Disclosure of Information

Following Health Insurance Portability and Accountability Act (HIPAA) rules, School Based Health Center staff members will use and share
my Personal Health Information (HPI) for: 1) treatment of my child’s health condition and maintaining the continuity of my child’s care, 2)
payment for health services provided to my child, and 3) routine health care operations including quality improvement, accreditation,
educational purposes, or other disclosures as required by law. I understand that The Notice of Privacy Practices document is available to me
at the location(s) my child receives his/her health care services and on the Tri-Area Community Health (TACH) website.
In order for health center staff members to provide services, I authorize the school to release school records on a “need to know basis” to
the School Based Health Center staff members, and also for the School Based Health Center staff members to release medical records to
the school, the health department, and my health care provider as needed to assist in the treatment and/or continuity of care for my child.
These records may include, but is not limited to the following; immunizations records, class schedules, parental/guardian contact, address,
phone number, medical and behavioral health conditions, health screenings, medications, health care plans, or attendance information.
The medical and mental health providers from the School Based Health Center may participate in student success or attendance teams if
needed. I also authorize other health care providers for the student listed above to release information to the School Based Health Center
staff members as needed.
I understand that if my child requires the School Based Health Services, reasonable attempts will be made to contact me and if I cannot be
reached, I give consent for my child to be seen by the providers at the clinic.
I hereby authorize the School Based Health Center to provide the services as indicated above. I authorize TACH to file my insurance for
services rendered. I request that payment be made directly to TACH. I understand that I am responsible for all charges incurred regardless
of my insurance status or lack thereof. Slide fee applications are available at www.triareahealth.org.

By signing this consent, I confirm I am the parent/legal guardian of the above listed student and am authorized to give
this consent. This consent will be in effect for one year from this date.
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Date

MonthDayYear
Date
Policies
Payment Policy

Payments

Payment is due at the time of service. Co-pays cannot be waived. We accept cash, checks, bank cards, money orders, MasterCard, Visa, and Discover.

Insurance

We will submit claims to most major insurance carriers including Medicare and Virginia Medicaid. Please bring your insurance card with you to every visit so that we can ensure that our records are accurate.

If your insurance requires a referral or prior-authorization for you to be seen at Tri-Area Community Health, it is your responsibility to obtain prior to your visit. If not obtained, you will be responsible for the charges.

Specific questions regarding insurance coverage should be addressed by your carrier, or our business office may be able to assist you.

No Show Policy

To ensure that each patient is given the proper amount of time allotted for their visit and to provide the highest quality care, it is very important for each scheduled patient to attend their visit on time. If it is necessary for you to reschedule or cancel your appointment, please call us at least 24 hours prior to your scheduled appointment.

If you arrive after your scheduled appointment, you may be asked to reschedule your appointment, in order to accommodate patients that have arrived on time.

Patients with repeated no shows and last-minute cancellations will be placed on an alternative appointment scheduling program. If placed on the alternative appointment scheduling program, patients may only schedule “same day” appointments as available and will not be allowed to pre-schedule appointments.

Tobacco/Vape Free Facility

Any use of any form of tobacco product, including any variation of e-cigarette or vape device, is strictly prohibited in any indoor or outdoor area of this organization, including personal vehicles on all grounds managed by the organization.
Should be Empty:

Patient Registration

Minors: (Please complete this section only if the patient is under 18)

Authorization for Permission to Discuss Protected Health Information

Patient Acknowledgement of Receipt of Notice of Privacy Practices

School Based Health Center Consent Form

Policies