Patient Registration Form

1. Be uninsured or have Medicaid.
2. Be over the age of 18.
3. Live in Virginia.
4. Meet certain low-income criteria.

Low Income Criteria

Since Bradley Free Clinic exists to serve low income, uninsured, or underinsured residents of the Roanoke Valley and surrounding areas, not everyone qualifies to be a patient. If you have questions about patient registration, please call our office at 540-344-5156.

Bradley Free Clinic is a non-profit organization that relies heavily on donations and volunteer support to keep our operation going. You can get involved in the following ways:

1. Donate
2. Volunteer

You will need:

1. Photo ID (preferably a driver's license or government issued ID card).
2. Paystubs for the last 30 days or your most recent tax return.
3. Health insurance card (if applicable).
4. Proof of residency (statement or bill addressed to you and received within the last 30 days, or a letter of support).

Once you have these documents ready, click "I'm ready to begin." It will take you approximately 10-15 minutes to complete the form. Answer all questions as accurately as you can.

Household Information
(yourself + spouse + tax dependents = household)

Household income, not individual income, is used to determine eligibility. Individuals with a household income less than 300% of the federal poverty level qualify to receive services at Bradley Free Clinic.

If you need assistance understanding the eligibility process, please call our office at (540) 344-5156.

HIPAA Notice of Privacy Practices Statement

How We Collect Information About You:
Bradley Free Clinic (BFC) and its employees and volunteers collect data through a variety of means including but not necessarily limited to letters, phone calls, emails, voicemails, and from the submission of applications that are either required by law or necessary to process applications or other requests for assistance through our organization.

What We Do Not Do With Your Information: 
Information about your financial situation and medical conditions and care that you provide to us in writing, via email, on the phone (including information left on voicemails), contained in or attached to applications, or directly or indirectly given to us, is held in strictest confidence.

We do not give out, exchange, barter, rent, sell, lend, or disseminate any information about applicants or clients who apply for or actually receive our services that are considered patient confidential, restricted by law, or specifically restricted by a patient/client in a signed HIPAA consent form.

How We Do Use Your Information: 
Bradley Free Clinic has a multi-disciplinary team of providers, community health workers, care coordinators, and case managers who collaborate as appropriate to ensure that your health care needs are met. This integrated care team will regularly discuss your care, and all team members have access to your protected health information (PHI), including, but not limited to, behavioral health/substance use disorder diagnosis and progress notes. Information is only used as is reasonably necessary to process your application or to provide you with health or counseling services which may require communication between BFC and health care providers, medical product or service providers, pharmacies, insurance companies, and other providers necessary to verify your medical information is accurate and determine the type of medical supplies or health care services you need. This is including, but not limited to, or to obtain or purchase any type of medical supplies, devices, medications, or insurance.

If you apply or attempt to apply to receive assistance through us and provide information with the intent or purpose of fraud or that results in either an actual crime of fraud for any reason including willful or un-willful acts of negligence whether intended or not, or in any way demonstrates or indicates attempted fraud, your non-medical information can be given to legal authorities including police, investigators, courts, and/or attorneys or other legal professionals, as well as any other information as permitted by law.

BFC shares medical and financial information with other health facilities, Rx Partnership, Direct Relief Replenishment, and pharmaceutical companies (or their designees) for eligibility verification and auditing purposes.

Information We Do Not Collect: 
We do not use cookies on our website to collect date from our site visitors. We do not collect information about site visitors except for one hit counter on the main index page (bradleyfreeclinic.com) that simply records the number of visitors and no other data. We do use some affiliate programs that may or may not capture traffic date through our site. To avoid potential data capture that you visited a diabetes website simply do not click on any of our outside affiliate links.

Limited Right to Use Non-Identifying Personal Information From Biographies, Letters, Notes, and Other Sources: 
Any pictures, stories, letters, biographies, correspondence, or thank you notes sent to us become the exclusive property of Bradley Free Clinic. We reserve the right to use non-identifying information about our clients (those who receive services or goods from or through us) for fundraising, promotional, and grant purposes that are directly related to our mission.

Clients will not be compensated for use of this information and no identifying information (photos, addresses, phone numbers, contact information, last names or uniquely identifiable names) will be used without the client’s express advance permission.

You may specifically request that NO information be used whatsoever for promotional purposes, but you must identify any requested restrictions in writing. We respect your right to privacy and assure you no identifying information or photos that you send to us will ever be publicly used without your direct or indirect consent.

Patient Rights and Responsibilities

• I understand that Bradley Free Clinic (BFC) may be able to provide an initial referral for an outside service. BFC must schedule all appointments with outside providers. I understand that any labs, imaging, or follow-up visits that are a result of this referral will be my financial responsibility.

• I understand that BFC has an agreement with Vistar to provide reduced pricing for prescription eyeglasses for BFC patients. I understand that I am responsible for paying half of the cost of my prescription eyeglasses. Half of this payment is due at the initial visit and half is due to pick up the eyeglasses.

  I understand that any bills received from services received outside of BFC must be brought into the clinic within 30 days of the date on the bill.  If we are not notified before 30 days and the bill goes to collection, it is your responsibility to pay.

• Once establishing primary care or dental care at BFC, I will not continue to see another primary care provider and/or dentist. If I am only seeking dental services or behavioral health services, I will notify BFC of my primary care provider.

• I understand that no one may accompany me in the exam room for my visit, unless expressly approved by the provider. The patient must first see the provider and make this request.

• I will notify BFC of any changes in address, telephone numbers, household size, income, employment status, insurance status, and health information.

• I will treat all BFC staff, volunteers, and health care providers with respect, as they are to treat me. If I am intoxicated, disruptive, and/or use offensive language I will be asked to leave and may be dismissed from BFC.

• I must present my BFC card or Medicaid card during check-in at BFC or an outside provider to receive services. There is a $5 fee for a lost or stolen BFC card.

• I understand if I fail to keep an appointment or cancel/reschedule an appointment with less than 24 hours notice, it will be counted as a no-show. Once a patient has three no-show appointments, they may be subject to a fee or suspension. Two no-show appointments in the Dental Department will result in dental services suspension for six months. If I no-show my new patient dental appointment, I cannot be rescheduled for one year.

• I understand if I am 10 or more minutes late to an appointment, I will be asked to reschedule. I also understand I must arrive 15 minutes prior to appointment to complete check in process.

• It is my responsibility to complete the registration process annually, and update my registration at least two weeks’ prior to the BFC expiration date.

• I understand that I can discuss complaints, issues or concerns about patient abuse, neglect, misuse of property, patient safety, quality concerns, and other unresloved complaints with your provider and/or the Practice Manager.

• BFC relies on individual donations and if I am able, I will contribute.

If I receive a controlled substance prescription, I understand that:

• I must sign a controlled substance agreement to be added to my medical record.
• There must be no evidence of active illegal substance use, misuse, or diversion (based on urine drug screen).
• There must be a complete substance use history in medical record.
• There must be an updated Prescription Monitoring Report (PMP) with no evidence from the state registry of drug prescriptions from multiple providers in medical record.
• I must be respectful and polite to staff and volunteers at BFC. Foul language and/or belligerence toward staff or volunteers may result in your dismissal from clinical care at BFC.
• If you call for an appointment, you must notify the scheduler if you are requesting a controlled substance refill.
• No volunteer primary care clinicians are approved to prescribe controlled substances (whether the patient is uninsured or enrolled in Medicaid).

Once you submit this form, someone will review it and contact you. This process must be completed before you schedule an appointment. If you have any questions, please call 540-344-5156.