Health Brigade Registration

Let's get started!

To become a patient at Health Brigade, you must reside in Virginia and:
- Have Virginia Medicaid insurance coverage only. We do not see patients who have commercial insurance, Medicare, and/or veteran benefits.
  
  OR
  .
- Be uninsured and have limited income. See monthly income limits below.
- *You must make no more than the 200% FPL to qualify for medical services and no more than 350% FPL to qualify for counseling services.

Health Brigade Registration

Estimated Completion Time: 20 Minutes
Let's get the right forms for you.
YESNO
What type of insurance?
At this moment we do not see patients with medical insurance coverage other than Medicaid. If you wish to continue completing this form, you may still do so.
Please select your Managed Care Organization (MCO) for Medicaid

Patient Information
Legal Name*

First NameMiddle NameLast Name
Preferred Name
What should we call you?
Date of Birth *

MonthDayYear
Must be 18 or over
Cell Phone*
Area Code FirstFormat: (000) 000-0000.
Alternate Phone
Area Code FirstFormat: (000) 000-0000.
Email*
example@example.com
Social Security Number*
If no SSN, type "0"
Address*

Street Address

Apt #

City

Zip Code
City/County of Residence*

Household Information

Please list the names and relationships of the patient's family unit living in the house. The "Head of Household" must be the same Head of Household in the tax return.
OwnRentLive with family or friendLive in shelterOther
Head of Household
Name

First NameLast Name
Date of Birth

MonthDayYear
Must be 18 or over
Relationship to Patient
Social Security Number
If no SSN, type "0"
Family Members in House
If you filed taxes last year AND claimed someone who DOES NOT live in your household, please list those persons below:

Income Information

Please list the amount of income, before taxes, earned by ALL PERSONS in the family unit. Include the following types of income: wages/salary/self-employment, child support/alimony, interest/dividends, disability benefits, retirement benefits, Social Security income, unemployment benefits, and any other type of income. Do not include income from loans.
Household Income Information
If no income is received, how do you provide food and shelter for yourself/family?
If no income is received, how do you provide for other daily living expenses (i.e., help with bills, medications, etc.) for yourself/family?

Access Now - Authorization to Share Health Information and Records

Health Brigade Registration
Patient Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
I authorize Access Now, Inc. to discuss and share my Protected Health Information (PHI), health records and health information with the following person(s):
Authorized Individuals
As the person signing this authorization, I understand that it will remain in effect until I submit a new authorization form to Access Now, Inc., which I may do at any time. I understand that if a new authorization is submitted to Access Now, Inc., any previous authorization will be cancelled and no longer valid. I also understand that once information is shared by Access Now, Inc. with an authorized person, the information may not be kept to the same privacy standards by the recipient.
Signature

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Relationship to patient (if not the patient)
Date

MonthDayYear
Date

Access Now - Patient Rights and Responsibilities

Health Brigade Registration
I, First Name Last Name, understand and agree to the following:
- I will promptly supply all information requested by Access Now.
  - If I see a doctor or receive care in a hospital and am asked to provide any additional information and/or complete any additional paperwork, even though I have an Access Now card, I will provide this information as requested.
- I authorize all individuals and entities to share my medical and financial information with Access Now.
- I authorize Access Now to share my financial and medical information with medical clinics, doctor’s offices and hospitals to coordinate my treatment.
- I will notify Access Now and my primary care clinic if my income changes or if I become covered by an insurance plan (including Medicaid/Medicare). I understand that failure to do so may result in disenrollment from the program.
- I will keep all appointments with Access Now specialists or cancel an appointment at least 24 hours in advance.
- I understand that if I miss any two appointments, consecutively or not, without appropriate advance notice, I will be disenrolled from Access Now and no services will be available to me any longer.
- I will present my Access Now identification card to the physician’s office at the time of my appointments.
- I will behave appropriately while at and in communication with the physician’s office and understand that failure to do so will result in disenrollment from Access Now.
- I will follow my doctor’s treatment plan, including taking prescribed medications.
- I will return to my primary care clinic prior to the expiration date on my enrollment card if I need continued or additional care.
- I understand that if I receive a bill related to Access Now services I need to call 804-622-8145 to report the bill to Access Now.
By signing below, you indicate that you understand and agree to all patient rights and responsibilities in this document.
Signature of Patient/Guardian

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Date

MonthDayYear
Date

Access Now - Patient No-Show Policy

Health Brigade Registration
I, First Name Last Name, understand and agree to the following:
- I will keep all appointments with Access Now specialists because available appointments through the Access Now program are limited.
- If I need to cancel or reschedule, I must contact the specialists' office directly as soon as possible and will give no less than 24 hours notice.
- If a surgery appointment needs to be changed I understand more than 24 hours notice needs to be given and I will try to give at least one week’s notice.
- If there is an emergency and I cannot keep an appointment I will let the specialists’ office know immediately.
- My specialist’s office may have a different no show policy than Access Now and Access Now will follow my specialists’ office policy.
  - No-show policies can be different for each office I may go to and some may refuse to continue treating me or require that I pay a no-show fee which I will be responsible for paying
  - The decision of the specialist’s office is final
- If I miss two appointments within one year without giving appropriate notice that I cannot make it to the appointments, I will be disenrolled for one year.
  - If I am disenrolled for one year after missing two or more appointments, I can re-apply for the Access Now program and if I qualify, I will be on a one year trial period where, at any point, if I have one no-show, I will be disenrolled from Access Now permanently.
  - If I complete my one year trial period without any no-shows, I will be reinstated fully which means I will not be disenrolled again unless I no-show to two appointments within a one year time frame. If I no-show to two appointments within one year again, I will be disenrolled from the program permanently.
By signing below, you indicate that you understand and agree to comply with the Access Now – Patient No-Show policy.
Signature of Patient/Guardian

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Date

MonthDayYear
Date

Privacy Agreement

Health Brigade Registration
Patient Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
I give Health Brigade the permission to discuss and share information regarding my care to those listed above. (Lab results, appointment reminders, medication pick up, etc.)

I understand that this consent will remain in effect for one year and may be revoked at any time.
Consent to Share Health Information
Signature of Patient/Guardian

Clear
Date

MonthDayYear
Date

Pharmacy Assistance Contract

Health Brigade Registration
Patient Name

First NameMiddle NameLast Name
Preferred Name
What should we call you?
Date of Birth

MonthDayYear
Date
YesNo
NOTE: If you filed, you MUST provide us with a copy in order to receive medication. You can obtain a copy by calling 1-800-829-1040.

By signing this contract, I agree to the following:
- I will keep all my appointments at Health Brigade
- I will keep all my information up to date including address and telephone number(s)
- I give the Pharmacy Program Assistants permission to sign any necessary paperwork on my behalf.
- When I have only 1 month of medication left, I must call the Pharmacy Program Assistant to reorder.
- I understand that the program is a privilege and is subject to change or termination at any time.
In the event of my absence, I grant First Name Last Name permission to pick up my medication for me.
Patient Attestation/AMP Acknowledgement of Pharmacy Services

Please select each box if you agree to its corresponding statement.
I, First Name Last Name, attest:
This information is true and accurate. I do not have prescription drug coverage. Iunderstand it is my responsibility to inform the clinic immediately of any changes to my income, household size, or insurance status. I authorize the clinic to share medical and financial information with Rx Partnership and pharmaceutical companies (or their designees) as required for eligibility verification during routine audits.I understand that a pharmacist will fill my prescription in an offsite pharmacy (Lloyd F. Moss Free Clinic Pharmacy). I understand I have a right to take my prescription to a retail pharmacy of my choice.
Patient Signature

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Date

MonthDayYear
Date

Dear Patient/Responsible Party.

We are providing this application, because you may qualify for our Financial Assistance Program.

To be eligible for the program, you must have applied for Medicaid, State or Local Assistance and have been denied, because you do not meet the requirement for an application.

The attached form only applies to hospital bills, and does not include any other medical bills you may have; such as physician, radiology, ambulance, etc.

In order to be considered for a full or partial assistance, you must complete the Financial Assistance Application. The responsible party must sign the bottom, and return the completed application within fourteen (14) days of receipt.

Inpatient Visits: If you were admitted into the hospital as an inpatient, it is necessary for you to provide us with your latest Federal Tax Return for supporting documentation. If you did not file a tax return, please indicate and attach any two of the documents listed below.
- State Income Tax Return
- Employer Pay Stubs
- Written documentation from income sources
- Copies of all bank statements for the past three months
Medicare Patients: If you are covered by Medicare, it is necessary for you to provide us with your latest Federal Tax Return for supporting documentation. If you did not file a tax return, please indicate and attach any two of the documents listed below.
- Supporting W-2
- Supporting 1099’s
- Most recent bank and broker statements
- Qualified Medicare Benefits
If, for any reason, you cannot provide us with the requested information, please attach a written statement explaining why you cannot provide the information requested.

Please allow ten (10) business days for our review process. We will notify you of our assistance determination by letter. If you have any questions or concerns, please feel free to contact Customer Service at any time at (800)799-6478.

Remember if you return the Financial Assistance Application your bill may be included in our Financial Assistance Program.

Please return your completed application with required supporting documentation to:

HCA-Patient Account Services
Attn: Financial Assistance Department
P.O. Box 13620
Richmond, VA 23225

Financial Assistance Application

Health Brigade Registration
Hospital Name
Account Number
Patient Name

First NameLast Name
Patient's Social Security Number
Responsible Party

First NameLast Name
Employer Name
Responsible Party's Social Security
Dependents in Household
This includes spouse, children under 18, and all others claimed on your tax return.
Employment
(Patient or Responsible Party)
Employer Name
Hourly Rate
Hours Worked per Week
Current gross weekly, monthly, or yearly income (before taxes):
If unemployed, date last worked:

MonthDayYear
Date
Spouse Employment
Employer Name
Hourly Rate
Hours Worked per Week
Current gross weekly, monthly, or yearly income (before taxes):
If unemployed, date last worked:

MonthDayYear
Date

Other Income

Rows	Patient	Spouse
Social Security
Pension
Unemployment
Worker's Compensation
VA Benefits
Rental Income
Stocks, Bonds, 401k
Dividends/Interest
Child Support
Alimony
Other

YesNo
I, the undersigned, certify that the above information is true and accurate to the best of my knowledge. I understand that the information submitted is subject to verification. In the review process, a credit report may be requested to verify information provided in this application. I understand that falsification of information submitted may jeopardize my consideration for the program. Furthermore, to qualify for this program, I understand I must apply for any and all assistance that may be available to help pay this hospital bill prior to completing this application.
Signature

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Date

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Date

Patient Rights and Responsibilities

Health Brigade Registration
Real Financial Cost of Services at Health Brigade

If you were to pay the actual cost for a medical visit or Metal Health Services at Health Brigade, you would owe over $200.00 per visit and this does not include lab work, radiology, or medications. With that said Health Brigade is a non-profit organization that survives on grants and donations from individuals like you, a contribution per visit is recommended and well appreciated.
Please do not stop coming for you medical care because of your standard contribution. You will still receive care if you cannot make your contribution. We will work with you.
Specialty Referral Program

As a client of Health Brigade you will have access to primary medical care. Should you need specialty medical care, Health Brigade works with Bon Secours, VCU Health Systems and the Richmond Academy of Medicine (ACCESS NOW) to provide that coverage.

If you have not been a resident of Amelia County, Caroline County, Charles City County, Chesterfield County, Cumberland County, Dinwiddie County, Essex County, Gloucester County, Goochland County, Hanover County, Henrico County, Isle of Wight County, King and Queen County, King George County, King William County, Lancaster County, Louisa County, Mathews County, Middlesex County, New Kent County, Northumberland County, Powhatan County, Prince George County, Richmond County, Southampton County, Surry County, Sussex County, Westmoreland County, City of Colonial Heights, City of Hopewell, City of Petersburg, City of Richmond, Town of Ashland for the past 6 months you will be required to obtain specialty coverage through either VCU or Bon Secours. All applicable application information will be provided.

Services at Health Brigade will not change, but you will not have access to specialty services until the 6 month time frame has been met.
Partners:

Health Brigade places you at the center of how we care for you. We believe you should have access to safe, high quality, well-coordinated, comprehensive, and culturally responsive care that will assist you in achieving and maintaining the best health possible both physically and mentally. Our Health Care Team is here to work with you in partnership.
Guidelines & Expectations:

Health Brigade is a non-profit organization that survives on grants and donations from individuals and funders who trust and expect us to provide the best services to the greatest number of people who need them. We are committed to ensuring that our staff and volunteers treat our clients professionally and respectfully at all times, and likewise we expect the same in return from our clients.

Our resources are limited and therefore we work very hard to ensure that our staff and volunteers’ time of giving their service is well utilized. Therefore, we ask you to commit to the following:
- If you miss your first medical appointment, the earliest you may be able to reschedule will be 3 months from the original appointment. 24 hours’ notice is expected if you need to cancel an appointment. If you fail to cancel an appointment, it will count as a NO-SHOW. After three (3) no-shows in a 12-month period, services may be suspended for one year. IF you arrive 15 minutes late, it is very likely you may not receive treatment that day and will have to reschedule.
- For the health and safety of all who come to Health Brigade for any reason, the following are prohibited from the premises: weapons of any kind, illegal substances, tobacco use, and/or inappropriate, threatening, or violent behavior. A violation will result in immediate and permanent loss of services and access to the premises.

HIPAA Notice of Privacy Practice

Health Brigade Registration
The HIPAA Privacy Rule, a Federal law, gives you rights over your health information and sets rules and limits on who can look at and receive your health information. The Privacy Rule applies to all forms of a person’s protected health information, whether electronic, written, or oral.
Your health records include:
- Information your doctors, nurses, and other health care providers put in your medical record.
- Conversations your doctor has about your care or treatment with nurses and others.
- Information about you in your health insurer’s computer system.
- Most other health information about you is held by those who must follow these laws.
Your Rights to Your Health Information:
- The right to see or get a copy of your health information. Ask us how to do this.
- The right to request a change if you feel the information in your health record is incorrect or incomplete. We may say “no” to this request, but if we do, we will tell you why in writing within 60 days.
- The right to ask us to limit what health information we share. We are not required to agree to this request, and we may say “no” if it would affect your care.
- The right to request confidential communications – you can ask us to contact you in a specific way, such as by home or office phone number.
- The right to a list of those with whom we’ve shared your health information over the past 6 years prior to when you make the request.
- The right to choose someone to act for you, such as a legal guardian, and to choose who you would like us to share information with, such as a family member.
- The right to receive a copy of this notice.
- The right to file a complaint with the Medical Director at Health Brigade, or with the Department of Health and Human Services. We will not retaliate against you for filing a complaint.
Reasons we can share health records without your permission:
- To treat you. For example, if a doctor treating you for an injury needs to know about your overall health.
- To run our organization. For example, to improve your care by monitoring your health information.
- To bill for your services.
- To help with public health and safety issues. For example, for preventing disease in a pandemic, or preventing a serious threat to someone’s safety.
- To do research. All research projects are subject to a special approval process that is designed to protect your information.
- To comply with the law. In response to a court order, subpoena, warrant, summons or similar process.
- To respond to organ and tissue donation requests.
- To work with a medical examiner or funeral director.
- To address workers’ compensation, law enforcement and other government requests.
- To respond to lawsuits and legal actions. If you are involved in a lawsuit, we may disclose medical information about you in response to a court or administrative order, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Our Responsibilities:
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if something happens that may have compromised this privacy andsecurity.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us that we can inwriting. If you tell us we can, you can change your mind at any time, and must let us know in writing.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
I acknowledge that I have received the HIPAA Notice of Privacy Practice. I also understand that I may obtain a copy of the protected health information described in this consent.
Signature

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Date

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Telehealth Policy

Health Brigade Registration
Appointment Options

Appointments may be in person or via telehealth (see Telehealth Health Policy below). Telehealth visits may be virtual (by video) or by telephone. All paperwork (client agreements and rights) must be completed prior to the start of the first telehealth session.
Technology Requirements
- The dissemination, storage, or retention of identifiable information from the telehealth service shall comply with federal and Virginia state laws and regulations requiring individual health care data confidentiality.
- To participate in telehealth services, you must have access to a personal device that has a video camera and/or microphone. Examples include a computer, laptop, tablet, cellphone (iPhone or Android) or other telecommunication device. You will need internet access or the use of a cellular data plan for video telehealth appointments. You will need access to a telephone for phone sessions.
- Devices and telehealth apps used must be HIPAA compliant to preserve confidentiality. It is recommended that you keep your device protected and do not share any log-in information with others that you do not want to have access. HB cannot be held responsible for breach of confidentiality regarding your personal health information when log-in information has been disclosed by you, or someone you gave your log-in information to.
- Video telehealth appointments are conducted using a third-party HIPAA compliant web-based service that encrypts audio and visual information in accordance with federal telehealth standards. Video telehealth sessions are not recorded by the third-party service provider.
- Telehealth sessions through our mental health department (as well as in-person) can occasionally be recorded by HB for instructional purposes (graduate student training). You may decline a request to participate in session recordings without it affecting your right to continue receiving treatment or care. Written authorization would be needed from clients who consent to participate in instructional recordings.
- Neither providers nor clients are permitted to make unauthorized video or phone recordings of telehealth sessions. Clients who do not honor this restriction may no longer be eligible fortelehealth services.
Telehealth Restrictions

Due to legal restrictions providers at HB are not permitted to practice or provide services outside of Virginia. You must be physically located in the State of Virginia during your telehealth appointment.

Quiet, private, distraction-free environments where you cannot be overheard or interrupted by others are best for telehealth sessions. If anyone else is in the room with either the provider or the client during a telehealth session, all parties must be made aware of the other person’s presence. Consent must be granted by all parties for the session to continue. Your provider may reserve the right to cancel or
reschedule a telehealth session if they believe privacy, confidentiality, or safety will be compromised. Please note that clients will not be seen if they are driving and cannot pull over for their session.
Telehealth Practice Guidelines
- At the beginning of each telehealth session (video and/or phone session):
  - Your provider will state their name.
  - You will state your name and date of birth to verify your identity.
  - You will state your current physical location.
  - You will share your phone number (if using video) so your provider can call you back if video fails or becomes disconnected.
- Video sessions: A link will be provided to you to join the meeting at the scheduled appointment time. If you do not join the video meeting within 5 minutes, your provider will attempt to reach you by phone. The provider will be available for 10 minutes after the scheduled start. If the provider cannot reach you, the appointment will be canceled and marked as a no-show.
- Phone sessions: The provider will call you at the scheduled appointment time. If you do not answer, the provider will try again after 5 minutes and leave a message. If your provider does not receive a response within 10 minutes after the scheduled start, the appointment will be canceled and marked as a no-show.
You may attempt to reschedule the missed appointment by contacting the provider or our main scheduling line at (804) 358-6343.

Medicaid Patient Agreement

Health Brigade Registration
Health Brigade is a “Patient Centered Medical Home,” which means we place you at the center of how our medical team cares for you. We believe you should have access to safe, complete and kind care that will help you reach and keep your best health. Our Health Care Team is here to work with you.
Guidelines and Expectations

Health Brigade as a non-profit medical clinic asks you to agree to the following:
1. If I miss my first medical appointment, the earliest I may be able to reschedule that appointment will be 3 months from the original appointment.
2. I must try my best to give at least 24 hours’ notice if I need to cancel an appointment. If I fail to cancel my appointment, it will be a NO SHOW. I also understand that if I have three (3) NO-SHOWS in a 12-month period, my services may be suspended for one year.
3. I need to be on time for appointments and that if I arrive 15 minutes late, it is very likely I may not receive treatment that day and will have to make another appointment.
4. I will be treated professionally and respectfully by all staff and volunteers of Health Brigade and likewise, I understand that I am expected to interact respectfully at all times.
5. For the health and safety of all who come to Health Brigade for any reason, I understand the following are prohibited from the premises: weapons of any kind, illegal substances, tobacco use, and/or inappropriate, threatening or violent behavior. I understand that violations will result in immediate and permanent loss of services and access to the premises.
6. It is up to me to schedule an annual registration visit so I can continue to receive services.
I hereby voluntarily consent for me or my dependent to be interviewed, examined and treated by a licensed health professional or a trained Health Brigade Volunteer under the supervision of a licensed health professional. I request that suitable follow-up action be taken in the case of abnormal findings.I understand that if tests are taken for certain sexually transmitted diseases, reporting positive tests results to Public Health Agencies are required by law. I understand that the Health Agency uses this information to gather information about diseases, and offers a service to me to contact my sex and/or needle sharing partners, if I choose.
Signature

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Patient Rights

Health Brigade Registration
(from the AMA website) Code of Medical Ethics Opinion 1.1.3
- To courtesy, respect, dignity, and timely, responsive attention to his, her, their needs.
- To receive information from their physicians and to have opportunity to discuss the benefits, risks, and costs of appropriate treatment alternatives, including the risks, benefits and costs of forgoing treatment. Patients should be able to expect that their physicians will provide guidance about what they consider the optimal course of action for the patient based on the physician’s objective professional judgment.
- To ask questions about their health status or recommended treatment when they do not fully understand what has been described and to have their questions answered.
- To make decisions about the care the physician recommends and to have those decisions respected. A patient who has decision-making capacity may accept or refuse any recommended medical intervention.
- To have the physician and other staff respect the patient’s privacy and confidentiality.
- To obtain copies of their medical records.
- To obtain a second opinion.
- To be advised of any conflicts of interest their physician may have in respect to their care.
- To continuity of care. Patients should be able to expect that their physician will cooperate in coordinating medically indicated care with other health professionals, and that the physician will not discontinue treating them when further treatment is medically indicated without giving them sufficient notice and reasonable assistance in making alternative arrangements for care.

Privacy Agreement

Health Brigade Registration
Health Care Reminders

Health Brigade does not charge for this service, but standard text messaging rates may apply based on your wireless plan. I understand that this consent will apply to all future communication unless I request a change in writing.
I consent to receive text messages on my cellphone to remind me of an appointment, and I also agree to inform the Health Brigade if my cellphone number changes.I consent to receive voicemails regarding my appointment times, medications and/or lab results.I do not consent to receive text messages to remind me of an appointment.I do not consent to receive voicemails regarding my appointment times, medications and/or lab results.
Consent to Share Health Information
I give permission to discuss and share information regarding my care to those listed above. (Lab results, appointment reminders, medication pick up, etc.) I understand that this consent will remain in effect for one year and may be revoked at any time.
Signature

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You have completed your registration form!

Before you press submit, make sure your responses are correct.

Once submitted, you will recieve a link to submit any documentation required for your application.
Should be Empty:

Health Brigade Registration

Patient Information

Personal Details

Tax Filing and Veteran Benefits

Household Information

Employment and Benefits

Income Information

Access Now - Authorization to Share Health Information and Records

Access Now - Patient Rights and Responsibilities

Access Now - Patient No-Show Policy

Privacy Agreement

Medical Clinic Patient Agreement

Pharmacy Assistance Contract

Financial Assistance Application

Patient Rights and Responsibilities

HIPAA Notice of Privacy Practice

Telehealth Policy

Medicaid Patient Agreement

Patient Rights

Privacy Agreement