Get Va Central Virginia Health Services New Patient Registration Form 2020-2025

Completing the VA Central Virginia Health Services New Patient Registration Form online is a straightforward process designed to collect essential information to provide you with the necessary medical care. This guide will walk you through each section of the form to ensure all required details are filled accurately and efficiently.

Follow the steps to complete your registration form successfully.

1. Press the ‘Get Form’ button to access the registration form and open it in your preferred document editor.
2. Begin by filling out the patient information section. Input your first name, middle initial, last name, and any suffix. Include your preferred name if different.
3. Provide your mailing address, and include the street address if it is different. Ensure all contact numbers (home, cell, and work) are entered clearly.
4. Fill in your date of birth, city, state, and zip code. These details are crucial for identification purposes.
5. Indicate your sex and marital status by selecting the appropriate option.
6. Complete the gender identity and sexual orientation sections by selecting the options that accurately reflect your identity.
7. In the responsible party section, if you are the guarantor, you can leave it blank. If not, fill out the guarantor’s details, including their name, address, date of birth, sex, and phone number.
8. Specify if the guarantor is also a patient at CVHS.
9. Input emergency contact information, including the contact person’s name, relationship, and telephone number.
10. Fill out the employer information section by entering the name and address of your employer, as well as your primary medical insurance details.
11. Complete the insurance information section, including details for secondary insurance and dental insurance where applicable.
12. Provide demographic information such as county of residence, race, ethnicity, language, and veteran status.
13. Once all sections are completed, review the consent statements, initial beside each item to indicate understanding, then provide your signature, date, and a witness signature if required.
14. After making sure all information is accurate, you can save changes, download the completed form, print it, or share it as needed.

Start completing your registration form online today to ensure a smooth and efficient check-in process.