For your convenience, this One Form is available via eCheck-in in your MyVHC Patient Portal. VHC Health requires your authorization to deliver services.
Q: What is the new registration form name?
The “VHC Health Annual Access and Authorization to Treat” is a single electronic registration form that greatly streamlines the registration process across all VHC Health facilities.
Q: Why did VHC Health create a single registration form?
Patients have let us know they feel overwhelmed by the frequency and number of forms they need to read and sign to authorize treatment and accept financial responsibility at each visit to the hospital, outpatient clinics, and to their physician offices.
Previously, all patients were required to sign multiple forms including an Authorization to Treat form, a Notice of Receipt of Notice of Privacy Practices, Financial Guaranty form, among other documents upon each point of registration at each visit.
With a single combined registration form, we can capture all of the requirements in a one form, once per year, no matter which VHC Health location you visit.
Q: What forms were replaced by this single form?
-
- Authorization for Treatment
- Patient Rights and Responsibilities; (A copy will be given to inpatients on the unit. It is included in the patient handbook/admission packet)
-
Receipt of Notice of Privacy Practice
-
VHC Health Physicians (formerly VHC Physician’s Group (VHCPG) Consent for Treatment)
-
VHC Health Physician (formerly VHC Physician’s Group (VHCPG) Receipt of Notice of Privacy Practice)
-
Acknowledgement of Receipt of VHC Health Physicians Policies
-
VHC Health Pediatrics (formerly Arlington Pediatrics) APC Parent Consent Form
-
Financial Assistance Policy and payment guarantee language
Q: How long is the form valid?
The form is valid for one year from the date signed, unless you withdraw your consent, which may be done at any time.
Q: How is this form renewed every year?
A notice will display for registration staff and patients when it is time for patients to renew.
Q: What language is the form available in?
The form is currently available in English and Spanish, and our Language Line service can be of assistance if other languages are required.
Q: Can I fill out the form prior to my arrival?
Yes, there are many ways to complete the form. If you have a MyVHC portal account, you will receive a notification seven days prior to your scheduled appointment prompting you to fill out the registration form in advance of your arrival. This can be done from your computer, tablet or your mobile device.
Q: Can patient e-sign this form without a MyVHC portal account?
Yes, if you share your email address for this purpose.
Q: Can I complete the form when I arrive at the VHC Health Facility?
Yes, each VHC Health facility will have kiosks or tablets that can be used to review and complete the form.
Q: What if I don’t feel comfortable signing this form?
The contents of the single form are substantially identical to the content in the forms that were replaced and is consistent with other healthcare providers required registration forms.
In order to be treated at VHC Health, we need your written authorization and consent to deliver medical care and treatment to you. We similarly need your commitment to pay for the services rendered, as well as your acknowledgment of certain legal requirements.
Your signature authorizes VHC Health to deliver medically recommended care and treatment services to you.
Of course, patients always have the right to make informed decisions regarding all care and treatments, including the right to refuse any treatments you do not wish to receive, consult with your health care professional about the recommended care, consult with a spiritual advisor, and request an interpreter if one is needed.
Patients may also contact Patient Experience - 703.558.6195 (M-F 8:00 am -5:00 pm) to discuss any particular concerns or may contact the Nursing Supervisor after hours at 703.558.6131 or 703.907.8821.
Except for life-saving treatment, we CANNOT commence services without your authorization.
Q: What if a patient is unable to sign (ex. due to injury or isolation precautions)?
Registration staff will review the form with the patient and the patient can verbally authorize staff to initial the form on the patient’s behalf where indicated on the ‘Initial Here’ line.
Q: What if this patient is unable to sign or give verbal authorization?
When a patient is unable to sign or provide verbal authorization due to reasons such as an emergency, incapacity, or unconsciousness, registration staff will assist with registration. At the next visit, patients will be required to sign the registration form. Signature is required for full year coverage.
Note: Patients will be required to sign the registration form upon their next visit. Signature is required for full year coverage.
