Wellness-New Patient Screening

New Patient Screening

Wellness Center
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Phone Number *

Area Code Phone Number
Social Security Number *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Gender Identity *
Race *
Ethnicity *
Do you have medical insurance? *

Yes No
Insurance Name *
Referring agency *
Referred by *
ALL NEW PATIENTS SHOULD BRING THE FOLLOWING DOCUMENTATION TO THE INTIAL VISIT:

Two forms of identification to include:
- Picture ID
- Proof of residence ( Valid documentation includes: utility bill, lease, voter card w/ name and current address)
ONE of the items listed below:
- If employed – last three pay stubs, last tax return or w2 form
- If not employed- notarized letter with name / address of person providing food/shelter
- Other income: Unemployment Compensation, Disability or SSI letter
Insurance Documentation:
- Private insurance card/Medicaid Card/Medicare Card
- If you are uninsured, just let us know
No Income and Address Verification Documentation

In the event you do not have valid forms of documentation according to the lists above, please have the "No Income and Address Verification Letter" completed and notarized.

Click here to download the "No Income and Address Verification Letter"
Questions
1. Have you been diagnosed as HIV positive? *

Yes No
Date of HIV Diagnosis
Where:
Have you ever received care for your HIV? *

Yes No
Date of last visit
Where:
2. Have you been discharged from the hospital in the last month? *

Yes No
Which hospital /diagnosis:
3. Have you been discharged from a correctional facility in the past month? *

Yes No
Which facility:
4. Are you now sick or have been sick in the past 2 weeks? *

Yes No
Please explain:
5. Have you ever been or are currently taking medication for HIV? *

Yes No
Last regimen prescribed:
6. Have you had any recent lab work done? *

Yes No
When:
Where:
7. Do you have any immediate medical need at this time? *

Yes No
8. What location would you like to receive your HIV care? *

Vernon J. Harris Medical Center- 719 N. 25th Street, Richmond, VA 23223 Bermuda Medical Center- 2740 Bensley Commons Blvd., Richmond, VA 23237
Upload Documentation
In order to assist with patient screening and enrollment, please upload the following documentation if available. All uploads are secure and confidential.
- Patient ID
- Proof of residency
- Income Verification documentation
- Insurance Card
- Other documents
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New Patient Screening

Questions

Upload Documentation