LAUREL FORK ENGLISH PATIENT REGISTRATION FORM

PATIENT REGISTRATION

Neighbors Caring for Neighbors
Patient Information
Name

First NameMiddle NameLast Name
Preferred 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
Please enter a valid phone number.
Email
example@example.com
Birth Date

MonthDayYear
Date
Age
Sex at Birth

MaleFemal
Social Security Number
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

YourselfSpouseBiological ParentGuardian
Responsible Party Name (if other than yourself)

First NameLast Name
If you checked yourself as "Responsible Party" you do not have to add the address and other information in this Responsible Party Section.
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 Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Birth Date

MonthDayYear
Date
Minors

If patient is under the age of 18, please complete the following:
Please list other parent/guardian if applicable:
Is Child in Foster Care?

YesNo
If yes, please complete Foster Care Form.
Insurance Information
Do you have health insurance? (if no, skip to Emergency Contact)

YesNo
Name of Insurance
Name of Policyholder
Who is the Policy Holder

SelfSpouseMotherFather
Social Security Number or Policy ID Number
Policyholder Birth Date

MonthDayYear
Date
Type of insurance

MedicareMedicaidOther
Please list any secondary insurance
Emergency Contact Information
Emergency Contact (other than your 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
Preferred Pharmacy Location
City
Preferred Pharmacy Phone Number
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

MarriedSingleWidowedOther
Race (if more than one, check all that apply)

American Indian or Native AlaskanBlack or African AmericanAsian IndianChineseFilipinoJapaneseKoreanVietnameseOther AsianNative HawaiianOther Pacific IslanderGuamanian or ChamorroSamoanWhiteMore than one raceUnreported/Choose not to disclose race
Ethnicity
Are you Spanish or Latino?

Yes, Mexican, Mexican American, Chicano/aYes, Another Hispanic, Latino/a or Spanish originYes, Puerto RicanYes, CubanNot Hispanic, Latino, or SpanishUnreported/Choose not to disclose
Preferred Language

EnglishSpanishOther
Is an Interpreter Needed?

YesNo
Are you a veteran? (choose one)

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

YesNo
Are you homeless?

YesNo
If homeless, where do you sleep at night?

ShelterStreetStay with friendsOther
Number of people in your household
Annual household income:

$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 us?

CollegeCommunity EventlFamily/FriendHealth Department/DSSNewspaperWebsite/Facebook, etc.Other
Authorizations and Certifications

Tri-Area Community Health
I HEREBY AUTHORIZE THE FOLLOWING:

·         Tri-Area Community Health (TACH) - 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 inurance 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.

·         Medical Lifetime Authorization Medical – for physical services and request that payment of authorized Medicare benefits to make either to me or my behalf to Tri-Area Community Health, Inc., d.b.a. Tri-Area Community Health (TACH), 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 given by the Virginia State Code to seek care and restrict access to their medical records for these types of services.

School Based Programs will follow the rules as established by the Governor of Virginia.

·         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.

·         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 Pathogens - 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 patients will not be tolerated. This includes assault, threats, verbal harrassment or cursing, or sexual language or unwatned 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 Signed

MonthDayYear
Date
If not self, what is your relationship to the patient?
Authorization for Permission to Discuss Protected Health Information
Patient Name

First NameLast Name
Birth Date

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

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

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Relationship to Patient
Date

MonthDayYear
Date
Please Note: The parent of a minor child has access to their child's PHI unless there is a court order stating otherwise or if the patient is a minor that falls under Virginia law asking for privacy. Court papers and/or court orders are to be provided prior to removing a parent's access, changes cannot be made without the proper legal documents, i.e., access cannot be blocked for one parent on the word of another parent.

When the patient turns 18, a new request and consent is required.
Patient Acknowledgement of Receipt of Notice of Privacy Practives
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 signed

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

Patient Information

Responsible Party Information

Minors

Insurance Information

Emergency Contact Information

Pharmacy Information

Ethnicity

Authorizations and Certifications

Authorization for Permission to Discuss Protected Health Information

Patient Acknowledgement of Receipt of Notice of Privacy Practives

Policies