NRH New Patient Registration Packet

WELCOME TO NEW RIVER HEALTH!

As your medical home, we are pleased to serve you and coordinate all of your healthcare needs. No matter your age or stage in life, we are dedicated to offering a wide range of services to meet all of your healthcare needs including primary medical care, behavioral healthcare, women’s healthcare and prenatal services, referral specialists, dental services, a full-service x-ray department, and on site lab services. We have convenient locations in Raleigh, Fayette, and Nicholas counties.

Additionally, we can provide dental, medical, and pharmacy sliding fee discounts to those who qualify. Qualification is based on your household income and family size.

We offer same-day appointments for sudden illness, and we also give you 24-hour on-call services in case you need urgent medical advice outside of regular business hours. For a serious emergency please always call 911 immediately.

We will provide our medical expertise so you can work toward a healthy lifestyle. We can only succeed as a team if the lines of communication are open – we want you to discuss all of your healthcare concerns with us and we promise to listen as well as we talk.

We recommend you schedule a visit to establish care and meet your healthcare team. We will get your medical history and have you sign a release to obtain any previous medical records so your healthcare provider can establish a plan to meet all of your wellness needs.

Please arrive 15 minutes early to your scheduled appointment so you can complete a brief registration packet. You will need to bring your medication bottles so staff can properly document your current medication list. Also bring your photo identification and proof of insurance. If you think you might qualify for sliding fee discounts, you should also bring documentation for proof of income.

We look forward to meeting you and serving all of your healthcare needs. To schedule your appointment or if you have any questions, please contact us at 304 469 2905.

Sincerely,

John R. Schultz, CEO

PATIENT REGISTRATION

Patient's Name:

Date of birth:

YYYY

Select date between arrows to add DOB

Birth City/State:

Social Security Number:

Cell Phone Number:

Home Phone Number:

Work Phone Number:

Mark which one is your preferred contact phone.

Cell phone

Home phone

Work phone

Check if we can or cannot leave nonprotected information on the voicemail (appointment reminders, etc.).

NRH can leave unprotected information

NRH cannot leave unprotected information

Employment Status:

Full Time

Part Time

Disabled SSI

Unemployed

Employer:

Patient Mailing Address:

Are you a veteran of any branch of the US Armed Forces?

Yes

Would you like to access your records through our Patient Portal website?

Yes

Email Address:

Ethnicity:

Non-Hispanic/Non-Latino

Hispanic/Latino

Sex:

Male

Female

Gender Identity:

Male

Female

Please check all that apply:
Race:

White

Native Hawaiian

Black or African American

American Indian or Alaska Native

Asian

Other Pacific Islander

Name of pharmacy and city:

Do you consider yourself:

Straight

Bisexual

Transgender

Lesbian/Gay

Prefer not to answer

Are you currently:

Married

Widowed

Divorced

Single

Separated

Required: All Records Kept CONFIDENTIAL

Head of Household Name:

Total Number of People in Household:

Gross Total Monthly Income of Household:

List each Household Member and his or her income below:

Name:

Date of Birth:

YYYY

Monthly Income:

Emergency Contact:

Relationship:

Phone Number:

HEALTH INFORMATION

Please mark any of the following conditions that apply to the patient:

Allergies (Seasonal)

Depression

Migraine Headaches

Alzheimer's

Diverticulitis

Mini-Stroke

Anemia

Diabetes

Neurologic Illness

Anxiety

Esophageal Reflux

Parkinson's

Asthma

Fibromyalgia

Obesity

Bleeding Disorder

Glaucoma

Osteoarthritis

Bipolar Disorder

Heart Disease

Osteoporosis

Carpal Tunnel Syndrome

Hepatitis B

Osteopenia

Congenital Heart Failure

Irritable Bowel Syndrome

Pneumoconiosis (Black Lung)

Congenital Abnormalities

Kidney Disease

Psychiatric Treatment

Convulsions

Liver, Stomach. or Bowel Disease

Stroke

COPD

Low Back Pain

Other:

Others medical conditions not listed:

Are you allergic to any medications?

Yes

Do you have any other allergies? (Such as food, pollen, insect bites, etc.)

Yes

If yes, what?

List current prescription & non-prescription medications you are taking:

Prescription or Non-Prescription medication

Dosage

Family Health History

Alcoholism

Child

Mom

Dad

Siblings

Grandparent

Aneimia

Child

Mom

Dad

Siblings

Grandparent

Asthma

Child

Mom

Dad

Siblings

Grandparent

Blood Disorder

Child

Mom

Dad

Siblings

Grandparent

Birth Defect

Child

Mom

Dad

Siblings

Grandparent

Cancer

Child

Mom

Dad

Siblings

Grandparent

Crohn's

Child

Mom

Dad

Siblings

Grandparent

Congenital Heart Problems

Child

Mom

Dad

Siblings

Grandparent

Congenital Abnormalities

Child

Mom

Dad

Siblings

Grandparent

Coronary Artery Disease

Child

Mom

Dad

Siblings

Grandparent

Drug Abuse

Child

Mom

Dad

Siblings

Grandparent

Epilepsy

Child

Mom

Dad

Siblings

Grandparent

Diabetes

Child

Mom

Dad

Siblings

Grandparent

Heart Disease

Child

Mom

Dad

Siblings

Grandparent

Stomach Problem

Child

Mom

Dad

Siblings

Grandparent

In the past year, have there been any changes in your family such as:

Birth

Loss of job

Separation

Death

Divorce

Marriage

Serious illness

Other:

Foster Care

Moved

Family incarceration

INSURANCE INFORMATION

Please complete all that apply and provide insurance number or copy of card

Insurance Carrier:

ID Number:

Group Number:

Card Holder Name for Private Insurance:

Birth Date of Card Holder:

YYYY

SSN of Card Holder:

Card Holder Address:

Complete Address for Private Insurance Carrier:

For Medicaid Insurance check the carrier:

Aetna

Unicare

The Health Plan

Molina

Highmark Health Options

Medicaid ID#: (11 digits)