• Pre-Appointment Registration

    Estimated time to complete: 5 minutes
  • **Please be advised of our in-office safety policies:

    1) You agree to call our office at 540-786-1200 if you feel sick or unwell. Any patient who feels sick or unwell will be offered a telemedicine appointment for your provider to decide if you can be seen in the office.

    2) You agree to wear a mask at all times. Patients without masks will not be seen in the office. If you do not wish to wear a mask, you will be required to schedule a telemedicine appointment. 

    3) You agree the patient will be the only person in the exam room. If the patient is a minor child or incapacitated adult, one person may accompany the patient.

    4) If you are a new patient, you agree to complete a medical history questionnaire upon completion of registration. You will be provided instructions to the questionnaire upon submission. 

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  • AUTHORIZATION TO USE/DISCLOSE PROTECTED HEALTH INFORMATION (PHI)

  • List names of those authorized to receive your PHI and their relationship to you. We will not discuss your PHI with anyone who is not listed by name on this form. Please include spouse, parent/legal guardian names, as applicable.

  • GUARANTOR/RESPONSIBLE PARTY INFORMATION


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  • INSURANCE INFORMATION

  • PRIMARY INSURANCE INFORMATION

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  • SECONDARY INSURANCE INFORMATION

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  • CERTIFICATION AND SIGNATURE

    I hereby attest that this information is true, accurate and complete to the best of my knowledge. Claims are submitted based on the information provided to PrimeCare at the time of service. I understand that any falsifications, omissions, or concealment may result in denial of services and claims. By e-signing this document, you agree your electronic signature is the legal equivalent of your manual signature.
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  • Treatment & Financial Policy Agreement

  • By signing below, you indicate you are the patient or have legal authority to consent to medical treatment on the patient’s behalf. You consent to, understand and agree to the following treatment policies:

    • The physician or provider will explain the risks and benefits of treatment and you will have the opportunity to ask questions and discuss your treatment plan

    • Prime Care strives to provide quality care based on accepted standards of medical practice but cannot guarantee results of treatment

    • Prime Care participates in the Virginia Prescription Monitoring Program which may be reviewed prior to prescribing any controlled substances

    • Prime Care reserves the right to refuse non-emergency services for any threatening, intimidating, or abusive behavior of any kind

    To provide the most cost-effective care, you consent to, understand and agree to the following financial policies:

    • If Prime Care participates with your insurance, claims will be filed as a courtesy if we have complete and accurate information at the time of service. This in no way relieves you of your financial responsibility for services rendered.

    • If Prime Care does not participate with your insurance, you will be considered self-pay and required to pay at the time of service, and any remaining balance will be collected upon check out. If you are covered under workers’ compensation and your claim is denied, a claim will be submitted to your private insurance on file or become your responsibility. We do not file claims to automobile insurance carriers.

    • You agree to pay at the time of service any required co-payments, co-insurance and deductible amounts, as well as non-covered services, outstanding balances, and delinquent accounts. We accept cash, checks and credit cards. If a check is returned for any reason, there is a $50 fee.

    • You agree to pay a $50 missed appointment fee if you miss/no-show or cancel within 24 hours of your scheduled appointment time.

    • You are responsible for, and agree to pay, the cost of any services that your insurance plan determines are not covered, or services that are covered but applied to a deductible. It is your responsibility to determine whether services to be provided by Prime Care are covered by your insurer.

    • If your insurance plan requires a referral from your primary care physician or insurance plan prior to a visit and you did not obtain the proper approval or referral, you agree to pay any costs determined not covered under your plan.

    • You assign Prime Care all health care benefits to which you are entitled under any policy of insurance and authorize, to the extent permitted by law, payment of those benefits directly to Prime Care.

    • The parent or guardian who brings the patient into our office will be held financially responsible, regardless of provisions in a divorce decree, custody agreement, or who is the policyholder.

    • You are responsible for paying balances in full unless payment arrangements are approved by Prime Care. For payment arrangements, you must contact our office. For questions regarding insurance payment, you must contact your insurance company directly.

    • All overdue accounts will be sent to a collection agency. You agree to be responsible for a $40 collection fee, and all associated legal fees, such as interest and court costs, in addition to the amount owed. 

    PLEASE NOTE: Prime Care reserves the right to deny non-emergency services for delinquent accounts.

    I certify that I received, read, understand, and agree to all the terms and conditions of the Treatment and Financial Policy Agreement as described above applicable to Prime Care Family Care, Inc. and its subsidiaries. I also acknowledge I received or was offered a copy of the HIPAA Notice of Privacy Practices. I agree my electronic signature is the legal equivalent of my manual signature on this Agreement.

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  • Telemedicine Informed Consent

  • Our providers do not address medical emergencies. If you believe you are experiencing a medical emergency, you should dial 911 or go to the nearest Emergency Department.

    Our staff typically respond to requests for telemedicine appointments as they are able, usually the same day, during normal business hours. However, response times may vary.

    If you have a primary care provider outside of PrimeCare, please note our providers are an addition to, and not a replacement for, your primary care provider. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.

    PrimeCare is not collecting co-payments for telemedicine services at this time. Due to the COVID-19 pandemic, many health plans are expanding telemedicine coverage. We highly encourage you to verify your coverage with your health plan, as cost-sharing waivers are payer-specific.

    By signing below, you indicate you are the patient or have legal authority to consent to medical treatment on the patient’s behalf. You consent to, understand and agree to the following treatment policies:

    1. I have the right to withdraw consent to the use of telemedicine services at any time and receive in-person healthcare services with my provider.

    2. I am physically located in Virginia. At the beginning of each telemedicine session, I agree to allow my provider to assess the suitability of using telehealth services by verifying my full name, current location, readiness to proceed, and whether I am in a situation conducive to private, uninterrupted communication.

    3. PrimeCare and its providers are located in the Commonwealth of Virginia and licensed by the Virginia Board of Medicine.

    4. PrimeCare's providers may not be able to assist me in the event of an emergency. If I require emergency care, I agree to call 911 or proceed to the nearest Emergency Department.

    5. Evaluation and treatment recommendations made in an online setting, including issuing a prescription via electronic means, will be held to the same standards of appropriate practice as those in traditional, in-person encounters.

    6. I may be refused telemedicine services if no practitioner-patient relationship exists. While each circumstance is unique, such practitioner-patient relationships may be established using telemedicine services provided the standard of care is met.

    7. It is the role of the provider to determine whether my condition being diagnosed and/or treated is appropriate for a telemedicine encounter.

    8. If at any time should my provider determines another form of services (i.e. traditional in-person visit) would be appropriate, my provider may discontinue telemedicine services. If my provider determines an in-person visit is more appropriate and requires the next available appointment, PrimeCare will not bill/charge for the telemedicine service rendered.

    9. I will not be prescribed any narcotics for pain, nor is there any guarantee that I will be given a prescription at all.

    10. I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

    11. I am comfortable with using electronic communications technology to communicate with PrimeCare and its providers. I understand there are limitations to the technology which may require an in-person visit at the direction of the provider.

    12. I have the right to access my medical information and obtain copies of my medical records in accordance with the laws Commonwealth of Virginia.

    13. Telemedicine services rendered to me will be billed to my health insurance company and that I will be billed for any patient responsibility as per my insurance.

    14. The laws that protect privacy and the confidentiality of my medical information also apply to telemedicine services. PrimeCare’s telemedicine service provider complies with the Health Insurance Portability and Accountability Act (HIPAA) Security Standards to ensure the security and privacy of patient data by employing industry-standard end-to-end Advanced Encryption Standard (AES) encryption using 256-bit keys.

    15. PrimeCare’s telemedicine services are conducted using an audio-visual, real-time, two-way interactive communication system and that no part of the live video encounter will be recorded without my written consent.

    16. My risks of a privacy violation increase substantially when I enter information on a public access computer, use a computer that is on a shared network, or use my work computer for personal communications. I also understand my failure to use technical safeguards, such as encryption, increases my risks of a privacy violation if I electronically send information to my provider.

    17. I acknowledge that I have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures.

    18. I agree to hold harmless PrimeCare Family Care, Inc. and its providers for information lost due to technical failures and I provide my express consent to forward patient-identifiable information to a third-party necessary for data capture and storage should I consent to recording.

    I certify that I received, read, understand, and agree to all the terms and conditions of the Telemedicine Informed Consent as described above applicable to Prime Care Family Care, Inc. and its subsidiaries. I agree my electronic signature is the legal equivalent of my manual signature on this Agreement.

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  • COVID-19 Screening

  • You must click "Submit Appointment" or your submission will not be received

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