• Part 2 Consent

    Part 2 Consent

  • Part 2 Consent form

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  • Why we are required to collect your social security number?
    Like all health care providers, we require your social security number to insure proper billing, treatment, access, and cataloging of your medical records.
  • Clear

  • I * authorize the Center’s Part 2 program(s) to disclose my behavioral health/substance use disorder records as follows:

  • Please be aware that we are an integrated site. It is imperative for us to be able to communicate with other members of your care team to provide you care. By selecting “None”, you are not consenting to be a part of this care team. Please meet with our Privacy and Compliance Officer prior to scheduling an appointment.

  • By selecting “None”, we will not be able to submit any of your prescriptions to your pharmacy. Please review your selection prior to submitting.

  • By selecting “None”, we will not be able to communicate with external providers. Please review your selection prior to submitting.

  • By selecting “None”, we will not be able to file your insurance for your visits to the Center. You will be considered self-pay and will have to pay in full for your visits. Please review your selection prior to submitting.

  • For additional purposes (if applicable): To authorize The Center’s Part 2 Program to disclose substance use disorder records to additional individuals and/or entities (such as to family members or to additional treatment providers) please complete this section:

  • By selecting “None”, we will not disclose information to additional individuals and/or entities (including family members or additional treatment providers). Please review your selection prior to submitting.

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  • I understand that I may revoke this authorization at any time provided that any such revocation is in writing and submitted to Bronie Reynolds, Compliance Program Manager, at Community Health Center of the New River Valley, 215 Roanoke St., Christiansburg, VA 24073, 540-381-0820, Breynolds@CHCNRV.org except to the extent that action has been taken in reliance on it. Acting in reliance includes the provision of treatment services in reliance on a valid consent to disclose information to a third-party payer.


    I understand the conditions of my treatment may be modified up to and including denial of services should I refuse to consent to the disclosure of my substance use disorder records, as permitted by state law.

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