Clinch River Health Services, Inc.
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    • Accessibility Statement
  • DIRECTIONS
  • PATIENTS
    • Patient Forms
    • Patient Centered Medical Home
    • Health Insurance
    • Immunization Schedules and Vaccine Assessment Tools
    • Patient Portal
    • Payment
  • ABOUT US
    • Our Impact
    • Board of Directors
    • Staff
    • History
    • FTCA
    • USDA/National Health Service Corps
  • SERVICES
    • Coordinated Care
    • Primary Health
    • Behavioral Health
    • Dental Care
    • Pharmacy Assistance
    • Migrant Health Network
    • More Programs
  • NEWS
  • Careers
    • Openings
    • Employment
    • Benefits

Patient Forms

Clinch River Health Services is committed to taking care of you, our patient. We hope to provide you with the best possible care in a warm and friendly environment. We have added a few pieces of information that will benefit you in understanding the care you will receive while a patient at Clinch River Health Services facility. Our goal is to help you feel better and get back to your regular activities as quickly as possible. 

New Patient Packets

Before your first visit...

Please complete and return form one week prior to your first appointment.
Medical forms
Behavioral Health Forms

Scheduling an Appointment

  • Most appointments are made for the day or within the week of your call. Please call early if you need a same day appointment.
  • If you are unable to keep your appointment, please call Clinch River Health Services to cancel or reschedule the appointment. 
  • Arrive on time for your appointment.  Call to notify Clinch River Health Services, inc. if you are going to be late. 

Other Forms

  • Virginia High School League Physical Exam Form​​​​
  • Commonwealth of VA School Entrance Health Form
  • UVA Wise Pre-Entrance Health Packet Form
  • School Bus Driver Physical Form
Authorization to Disclose Information
File Size: 189 kb
File Type: pdf
Download File

Self Declaration (Sliding Fee Program)
File Size: 125 kb
File Type: pdf
Download File

Release Income
File Size: 58 kb
File Type: pdf
Download File

Self Employment
File Size: 15 kb
File Type: pdf
Download File

Consent for Minors
File Size: 83 kb
File Type: pdf
Download File

Communication Preference
File Size: 18 kb
File Type: pdf
Download File

Patient Rights and Responsibilities
File Size: 109 kb
File Type: pdf
Download File


All patients have rights and responsibilities that ensure that you receive the best health care. 

All patients have the right …
  • To considerate and respectful care.
  • To be involved in your care.
  • To protection of your privacy.
  • To get help with your billing claims.
  • To share a complaint.
Speak to a front office manager or contact Administration for The Patient Grievance Procedure at (276) 467-2201.

All patients have the responsibility …
  • To be considerate and cooperative with Clinch River Health Services staff and fellow patients.
  • To be involved in your care.
  • To schedule and keep appointments.
  • To share honest and up-to-date information with us.

Notice of Privacy Practices
We create a record of the care and services you receive at Clinch River Health Services, Inc.  We need this record to provide you with quality care and to comply with certain legal requirements. We are committed to protecting your medical and personal information. Click here to download a copy of Clinch River Health Services Privacy Practices. 

Reminders

Bring all of your medications.

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Bring your Insurance Card.

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Whether you are a long time patient or haven’t been to see us in a while, the following is information that will help you plan your visit to Clinch River Health Services, Inc. and make your appointment go smoothly.
​
  • Bring all of your medications with you to every appointment.
  • Clinch River Health Services accepts most private insurance, Medicare, and Medicaid insurances.
  • If you cannot keep an appointment, please call Clinch River Health Services to cancel or reschedule the appointment.     
For Your Safety
  • All Clinch River Health Services, Inc. locations are smoke-free.  No smoking is allowed on the property, inside or outside the building.
  • Children in waiting rooms must be watched by parents or guardians.  We are not responsible for your child’s safety.
  • No weapons are allowed in any Clinch River Health Services, Inc. location. 

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  • HOME
    • Accessibility Statement
  • DIRECTIONS
  • PATIENTS
    • Patient Forms
    • Patient Centered Medical Home
    • Health Insurance
    • Immunization Schedules and Vaccine Assessment Tools
    • Patient Portal
    • Payment
  • ABOUT US
    • Our Impact
    • Board of Directors
    • Staff
    • History
    • FTCA
    • USDA/National Health Service Corps
  • SERVICES
    • Coordinated Care
    • Primary Health
    • Behavioral Health
    • Dental Care
    • Pharmacy Assistance
    • Migrant Health Network
    • More Programs
  • NEWS
  • Careers
    • Openings
    • Employment
    • Benefits