Insurance information and card upload
If you have been asked to complete this form, you have previously submitted paperwork missing a piece of information required for treatment at Giles High School Center of Community Health Center of the New River Valley. This form was created to allow you to submit missing information with the least inconvenience possible.
Student Name
First Name
Middle Name
Last Name
School name
Date of Birth
Insurance information
Does the student have Health/Dental Insurance? If you do not have insurance consider applying for for CHCNRV's sliding fee scale.
Yes
No
Name
First Name
Last Name
Policy Holder DOB
Parent / legal guardian signature
The information provided is, to the best of my knowledge and belief, accurate and true. I authorize the release of all information which the Community Health Center may need to determine whether I qualify for financial assistance through their Discount Fee Program. I understand that eligibility in the program expires 12 months from my signature date below and that I must reapply after the eligibility period expires. I understand that I must inform the Center of any changes in my household (income and size) during this 12-month period.
Date
-
Month
-
Day
Year
Date
Upload front of card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload back of card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: