New Patient Enrollment Form

Appointment Request *

Sick Visit (One Problem) Sick Visit (Multiple Problems) Annual Physical Behavioral Health CAHN Wellness

Additional information about your appointment request: (Please provide as many details as possible.)

Patient Name *

First Name Middle Initial Last Name

Date of Birth *

Month Day Year

Social Security Number *

Marital Status *

E-mail *

Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Preferred Contact Number: *

Area Code Phone Number

Preferred Pharmacy *

Pharmacy Name and Location

Preferred method of appointment reminder and/or communication:

Phone Call Text Messages (SMS) Email

Please upload an image of your photo identification. *

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Demographics

Race *

Ethnicity *

Are you a twin/multiple? *

Yes No

Language *

Sexual Orientation *

Gender Identity *

Please check all that apply: *

Migrant Worker Seasonal Worker Homeless Veteran Public Housing None of these

Number of people in Household: *

Estimated Household Yearly Income

By choosing to leave the estimated household yearly income blank, I decline my right to apply for the sliding scale discount program. *

Patient Portal

The patient portal gives you the ability to have a virtual visit with your provider. This is also know as a TeleVisit. You can have an appointment with your provider from anywhere. The portal also gives you access to the following:

~Appointments

~Lab results

~Medication request/Prescription refills

~Medical Records

~Direct messaging to your medical team

Would you like to register for the patient portal? *

Yes No, I decline at this time.

Patient Portal Authorization

The patient portal is designed to enhance secure patient-physician communications and is provided as a courtesy to our patients. Access to this secure web portal is optional and may be suspended or terminated at any time and for any reason. I understand that my access to the Patient Portal is entirely voluntary and will not impact the quality of care I receive from Capital Area Health Network (CAHN) and its affiliated healthcare providers, shall I decide against using the Patient Portal. In addition, I agree to adhere to the policies set forth herein, as well as any other instructions or guidelines that my physician may impose for online communication. I understand that this agreement will remain in effect for one (1) year. At the end of that time, I will be asked to renew my confidential email and Patient Portal login. I understand that I have a responsibility to protect my email account and secure password information, and that Capital Area Health Network will not be held liable for breaches of confidentiality arising from unauthorized use of such information.

Please Note: Do not use the Patient Portal for emergencies. Please Dial 911 or go to the nearest emergency room. If there is perrsistent abuse or negligence with the use of the Patient Portal, we reserve the rigth at our own discretion to suspend your account or modify services offered through the Patient Portal.

By signing, I confirm that I have read, understand and agree to comply with the policies and procedures set forth. I also agree not to hold Capital Area Health Network or any of its staff responsible for network infractions beyond its control. *

In case of emergency...

Emergency Contact: *

First Name Last Name

Relationship *

Contact Number *

Area Code Phone Number

Responsible Party/Guarantor

Responsible Party/Guarantor *

Self Someone Else

Responsible Party's Name *

First Name Last Name

Date of Birth *

Month Day Year

Contact Number *

Area Code Phone Number

Responsible Party's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Insurance

Do you have medical insurance: *

Yes No

Name of Insurance Company *

Policy Number

Group ID Number:

Please take a picture or upload an image of the FRONT of your insurance card.

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Please take a picture or upload an image of the BACK of your insurance card.

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Authorizaton for Use or Disclosure of Protected Health Information

Required by the Health Insurance Portabiity and Accountability Act (HIPAA)

Do you give permission to disclose private health information to family/friends? *

No, I would not like anyone else to have access to my information Yes, I would like to add a friend/family member

Name of Individual *

First Name Last Name

Relationship *

Contact Number *

Area Code Phone Number

I give access to the following: (Please check all that apply) *

Diagnosis/Procedures Treatment plans Appointments Test Results Billing Information

Authorizaton for Release of Private Health Information

o I authorize Capital Area Health Network, its agents or subsidiaries to release/receive all confidential healthcare records of the above listed patient.

o I understand that I have the right to revoke/cancel this authorization or limit this authorization to specific providers/facilities at any time except to the extent that prior action has been taken in reliance on this authorization. I understand that in order to revoke this authorization, I must do so in writing by notifying Capital Area Health Network prior to any actions or requests made regarding my information.

o I authorize the release of all information which may include information relating to sexually transmitted diseases, AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus), alcohol/drug treatment or use, behavioral or mental health services (including psychotherapy notes) and other communicable disease.

o I understand that authorizing the disclosure of this health information is voluntary and that I may refuse to sign this authorization. Capital Area Health Network nor any affiliated healthcare providers can make me sign this authorization as a condition to obtain treatment, making payments on any bills, or gaining eligibility for benefits unless allowed by law.

o I understand that by authorizing the disclosure of this protected health information, all of my records, including but not limited to history and physical exams, progress notes, laboratory reports, x-ray reports, immunization records, billing records and any other information pertaining to my health may be released to the identified person(s)/entities.

o I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by recipient and would then no longer be protected by federal regulations.

o I understand that there is a cost for a copy of my health information. In compliance with the Virginia Statute, I agree to pay a $10.00 administrative fee for my health records in addition to a fee of $.50 per page for up to 25 pages and $.25 per page thereafter.

o This authorization will remain active unless documented changes are made. This information will not be released without the appropriate signature.

o By signing below, I agree that I have received a copy of this authorization to release my information. I understand that copying charges will be applied according to Capital Area Health Network’s policies and procedures.

Advanced Health Directive

An Advanced Healthcare Directive (or Advanced Medical Directive) allows a person to describe his or her preferences in end of life situations.

Do you have an advanced health care directive? *

Yes, I have an existing one to add to my chart No, I would like to complete one I decline at this time

I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge. *

Clear

New Patient Medical Registration