Forms and Policies

CG3_5126Click the name of the item to the left of the description to download the document needed.

Spanish and Creole translation services available at Atlantic, Bayview, Chincoteague Island, Franktown and Onley centers.

Ofecemos servicios de interpretación en los centros de salud de Atlantic, Bayview, Chincoteague Island, Franktown y Onley.

Sèvis an kreyòl disponib nan sant sante: Atlantic, Bayview, Chincoteague, Franktown e Onley.

For questions on the forms below, please call the Corporate Office at 757-414-0400.

Este formulário tiene que ser completado antes de su primera visita con nuestro departamento dental. Para citas dentales en otros sitios que una oficina dental de ESRHS, este formulário es mandatorio al menos que su niño ha sido atendido para su chequeo físico por ESRHS dentro del año. Espanol: click hereTo authorize another adult to seek treatment for a minor child in the absence of a parent/legal guardian, the parent/guardian must indicate the authorized persons to seek treatment in section L of the minor child’s Patient Registration Form above. NOTE: this also will give the authorized adult complete access to the child’s medical/dental records.Para autorizar otro adulto a buscar tratamiento para un niño menor de edad en la ausencia de un padre/guardian legal , un padre/guardian legal necesita indicar las personas autorizadas a buscar tratamiento en la sección L del formulário mencionado arriba. AVISO: este también otorgará acceso completo al expediente médico y dental del niño a tal adulto autorizado.

Patient registration form​

Name Description
2017-employment-application Our application for employment form must be completed along with your resume when applying for position openings.
Chesapeake Bay Bridge Tunnel Ticket Application/Aplicación de Pases para el Puente Tunel Chesapeake

This form is required for all patients receiving CBBT tickets for their medical visits across the Bay. If multiple members of the same household are receiving tickets, each should fill out their own form. Please also bring a W2 or two paystubs with you the first time you request tickets. Tickets may be obtained from any Rural Health center. You do not need to be a Rural Health patient to qualify for this program.

Este formulario es necesario para todas las pacientes recibiendo pases de CBBT para sus visitas médicas al otro lado del Puente. Si varios miembros de la misma familia están solicitando pases, cada quien debe de llenar su propio formulario. Favor de traer una copia de su W2 o dos talones de cheque la primera vez que solicite los pases. Se puede obtener los pases en cualquier sitio de ESRHS. No es necesario ser paciente de ESRHS para calificar para este programa.

 

Patient registration form

Registro – Consentimiento del Paciente

This form must be completed prior to your first visit for any Rural Health service. For dental outreach appointments at locations other than a Rural Health dental office this form is required unless a child has seen a Rural Health medical provider for a Well Child Check within the past year.

Este formulário tiene que ser completado antes de su primera visita con nuestro departamento dental. Para citas dentales en otros sitios que una oficina dental de ESRHS, este formulário es mandatorio al menos que su niño ha sido atendido para su chequeo físico por ESRHS dentro del año. Espanol: click here

To authorize another adult to seek treatment for a minor child in the absence of a parent/legal guardian, the parent/guardian must indicate the authorized persons to seek treatment in section L of the minor child’s Patient Registration Form above. NOTE: this also will give the authorized adult complete access to the child’s medical/dental records.

Para autorizar otro adulto a buscar tratamiento para un niño menor de edad en la ausencia de un padre/guardian legal , un padre/guardian legal necesita indicar las personas autorizadas a buscar tratamiento en la sección L del formulário mencionado arriba. AVISO: este también otorgará acceso completo al expediente médico y dental del niño a tal adulto autorizado.

Medical Health History Form English

Formulario de antecedentes medicos: Medical Health History Form Spanish

Fòm pou Istwa Sante Medikal: Medical Health History Form Haitian Creole

This form must be completed prior to your first visit with our medical department.

 

Dental Health History Form

Formulario de la historia dental

This form must be completed prior to your first visit with our dental department.
Patient Rights and Responsibilities All patients have these rights and responsibilities.

Release of information form

Registro – Consentimiento del Paciente

Need to transfer your records to us? Fill out page 3 of this form and fax/mail it to your other provider’s office. You can even send this to specialists that you may see for your annual well woman exams (including PAP Smear) and Colonoscopy/Colorectal Cancer Screening.

Release of information form (FROM ESRHS)

Need to transfer your records FROM us? Fill out this form and fax/mail it FROM your other provider’s office.
Sliding Fee Application Update Jan 2017

We offer a sliding fee scale to patients who are uninsured or underinsured. Please fill out this form and bring it with you to your appointment. Also bring a W2 or two paystubs.

ESRHS ofrece un descuento deslizante a pacientes sin aseguranza de salud. Favor de llenar este formulario y llevalo a su cita, junto con su W2 o dos talones de cheque recientes.

Nou ofri yon rabè a tout pasian ki pa gen asirans oubyen ki pa gen ase asirans. Silvouplè ranpli fòm sa e pote l avè w nan randevou w la. Pote tou W-2 oubyen de reci chèk.

Virginia High School League Physical Exam Form For youth sports fill out this form and bring it to your child’s appointment.
Record Retention Under Virginia law, practitioners are required to maintain patient records for a minimum of six (6) years following the last time the physician encounters the patient. 18VAC85-20-26. There are, however, some exceptions to the six year retention requirement. In the case of a patient who is a minor, the physician is expected to maintain records, including records regarding immunizations, until the child reaches the age of 18 or becomes emancipated, or for six (6) years from the last patient encounter, whichever is later. 18VAC85-20-26(D)(1). Physicians do not have to retain patient records that have previously been transferred to another practitioner or healthcare provider or provided to a patient or his personal representative for six (6) years, but it is usually safest to maintain the original record even if the patient transfers to another provider. 18VAC85-20-26(D)(2). Physicians may be required by contractual obligation or federal law to maintain records for longer than six (6) years. 18VAC85-20-26(D)(3).