Patient Information

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
Date of Birth

MonthDayYear
Date
Sex at birth

MaleFemale
Email
example@example.com
Cell Number
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Preferred Method of Contact
Preferred Method of Contact
Are you a Veteran?
Social Security Number
Single

SingleMarriedDivorcedWidowed
Employed

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Information
Who is the insurance Policyholder?

SelfSpouseMotherFather
Policyholder Full Name

First NameLast Name
Policyholder Date of Birth

MonthDayYear
Date
Name of Insurance
Social Security Number or Policy ID Number
Emergency Contact
Emergency Contact Other Than Spouse
Relationship to You
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.
Pharmacy Information
Preferred Pharmacy
Preferred Phone Number
Please enter a valid phone number.
Pharmacy Addres
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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.
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

EnglishSpanishOthe
Is an Interpreter needed?

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 - $10,00010,000 - $14,99915,000 - $19,99920,000 - $24,99925,000 - $29,99930,000 - $34.99935,000 - $39,99940,000 - $49,99950,000 - $59,99960,000 - $69,99970,000 - $79,99980,000 - aboveChoose not to disclose
Current Gender

MaleFemaleOtherTransgender: Male to Female
Coose not to disclose

Coose not to disclose
Sexual Orientation

StraightLesbian or GayBisexualDon't knowChoose not to discloseOther
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. Deemed Consent for Designated Blood borne Pathogens: Virginia law requires health care providers to notify you that Hepatitis B and C or HIV (AIDS virus) testing on a sample of your blood may be done if a health care worker is exposed to your blood or body fluids. This following notice is to advise you that this is in effect at this facility. Under the Virginia Acts of Assembly Section 32.1-45.1, whenever any health care worker associated with o
Patrick County Family Practice Patients (only) in effort to coordinate patient care of patients seen in Stuart at Patrick County Family Practice records will be shared between Patrick County Family Practice and Tri-Area Community Health.

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.

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

MonthDayYear
Date
Authorization for Permission to Discuss Protected Health Information
Patient Name

First NameLast Name
I hereby give my permission to the person(s) listed below to receive information about my care.
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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
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.
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.
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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
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
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Date

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Date
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Patient Registration

Patient Information

Responsible Party Information

Insurance Information

Emergency Contact

Pharmacy Information

Pharmacy Addres

AUTHORIZATIONS AND CERTIFICATIONS

I HEREBY AUTHORIZE THE FOLLOWING:

Authorization for Permission to Discuss Protected Health Information

Patient Acknowledgement of Receipt of Notice of Privacy Practices

Policies

Payment Policy

No Show Policy

Tobacco/Vape Free Facility