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.

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 have read, understand and agree to follow all of the above.

1. 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. 

2. 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. 

3. I understand that a financial contribution is standard at the time of service based on an agreement that I have made during my annual registration visit. I understand that if I am unable to make the expected contribution at any time, I will still receive services and a health social worker will meet with me to work out a standard contribution rate I can pay. 

STANDARD CONTRIBUTIONS      

You will never  owe more than $30 max per month, no matter how many appointments you have. 

REAL FINANCIAL COST OF SERVICES AT HEALTH BRIGADE

If you were to pay the actual cost for a medical visit at Health Brigade, you would owe $140.00 to $160.00 per visit and this does not include lab work, radiology, or medications. If you were to pay the actual cost for a mental health visit at Health Brigade or out in the community, you would owe an average of $138.00 per visit.

I understand that a financial contribution is standard at the time of service based on the above amounts. I understand that if I am unable to make the standard contribution at any time, I will still receive services and a health worker will meet with me privately to work out a contribution amount I can afford to pay.

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.

• 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 Nowidentification 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.

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 the VCC program at VCU or the Care Card at 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.

I have read and fully understand the above mentioned program guidelines.