Please notice our hours
are subject to change.
forms & documents
We include a list of all of the forms and documents that are included in our Patient Packet. Because they are all available to you here, you have the opportunity to reference them, to read over them before your first appointment, or even print them ahead of time and fill them out. These forms will always be available to you in our office and there will always be a staff member available to go over the information with you if you have questions or need assistance with the forms. To view one of our forms or documents just click its title on the list below.
* Forms or documents that need to be signed or filled out are indicated by an asterisk.
We have a printable version of our Location and Map that you may want to bring with you on your first visit.
Downloadable Location & Map — English (442K)
Save time in the waiting room by printing and filling out this form prior to your arrival at the Harrisonburg Community Health Center. Locating key health information and important contact information before the scheduled appointment can also prove to be very helpful.
Downloadable New Patient Form — English (53K)
We understand that sometimes you need to cancel or reschedule your appointment. We do ask that you read our Cancellation and “No-Show” Policy. As a patient of the Community Health Center you must show that you understand and agree to follow our policy by signing it.
Downloadable Cancellation and “No-Show” Policy — English (70K)
In the forms below you will find a summary of all of the fee options that are available to patients at the Community Health Center.
The form below must completed for a patient to be considered for our Sliding Fee Discount program. This form must be completed each year that a patient wishes to be considered for our Sliding Fee Discount program.
Downloadable Sliding Fee Application — English (74K)
This program gives uninsured and low-income patients of the Harrisonburg Community Health Center access to reduced prices on prescriptions.
Downloadable Summary of the 340B Prescription Discount Program — English (146K)
We believe patient input during treatment is important to improving care, understanding, and treatment for our patients. We take the time to inform you of your rights and responsibilities as a patient at the Community Health Center because we always want you to feel we are working together as a team.
Downloadable Patient Rights & Responsibilities — English (147K)
This notice describes how medical information about you or your family may be used and disclosed and how you can get access to this information. It is being provided to you as a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Downloadable Notice of Privacy Practices — English (106K)
This form shows that you have read and understand your Patient Rights & Responsibilities and our Notice of Privacy Practices. This form also allows you to choose how the Community Health Center contacts you with your health information. Additionally, this form also allows you to name other individuals who can be contacted with your health information.
Downloadable Acknowledgement of Receipt of Forms — English (57K)
In order to protect patient confidentiality, Harrisonburg Community Health Center uses this form to get permission to get your medical records from another health provider. This form also allows you to choose how we release your medical information.
Downloadable Authorization for Release of Medical Records — English (57K)
The Harrisonburg Community Health Center works hard to take care of all of your health care needs. If we cannot take care of all of your health care needs at the Community Health Center we will connect you to other health care providers in our Medical Referral Network. This is not a complete list but includes contact information for providers that you can contact on your own or that we can help connect you with.
Downloadable Medical Referral Network — English (152K)
We are proud to provide the information to you to help you get to know our Primary Care Doctors, and Registered Nurses and Nurse Practitioners.
Downloadable Information on Our Providers — English (156K)
