PATIENT FEEDBACK FORM

Please complete the form below to tell us about your experience.

Please include the patient’s name and tell us how you are related to the patient. We also need the
NAMEs of the staff who have taken care of you.

Thank you for trusting us with your medical care. We look forward to serving you again.

You may send us and email at : admin@centercareva.com if you prefer that route.

ADULTS FORMS

NEW Patient Forms-ADULTS:

Establishing Primary Care Form- Adults

Medication List:

Problem List and Health Maintenance:

NEW PATIENT- DEMOGRAPHIC Form (ADULT)

HISTORY FORM-New Patient (ADULT)

Insurance Form

Consent for Treatment

Establishing Care Form (ADULT)

PEDIATRIC FORMS:

NEW Patients form- PEDIATRICS:

Establishing Primary Care Form- PEDIATRICS

Pediatric History Record:

School Physical form-VIRGINIA:

Sport Physical Form:

HPV Vaccines:

Establishing Care-Problem List And Heath Maintenance

NEW PATIENT- DEMOGRAPHIC Form (PEDIATRIC)

 HISTORY FORM – New Patient (PEDIATRIC)

Insurance Form

Consent for Treatment

General Forms

Office Policies

Patient Rights and Responsibilities

BLOOD GLUCOSE LOG

Medical Records Release form – patient 18yo and older

Medical Records Release Form- Pediatric Patient

Notice of Privacy Practice

MEDICAL RECORDS Request

Please complete the form and fax it as instructed below

Fax the form to:

  • 888-801-8599, if you live in King George
  • 540-699-0214, if you live in Fredericksburg
  • 540-322-2706, if you live in Locust Grove

Medical Records Release Form:

https://acrobat.adobe.com/id/urn:aaid:sc:
US:2e2036ce-e7f7-41a1-95b2-08eac9554150

HELPFUL LINKS:

Health Insurance: Do you need Health Insurance?

https://www.healthcare.gov/

MEDICARE PREVENTIVE CARE SERVICES

https://www.medicare.gov/publications/
10110-Your-Guide-to-Medicare-Preventive-Services.pdf

Medicaid Information-Virginia:

https://www.dmas.virginia.gov/

Medicaid Information

https://coverva.dmas.virginia.gov/apply/health-plans/#:~:text=To%20change%
20your%20health%20plan%20online%2C%20select%20%E2%80%
9CEnroll%E2%80%9D%20and,800%2D817%2D6608).

Medicaid Formulary

https://www.dmas.virginia.gov/for-members/
prescription-drug-formularies/

Medicaid- How to Change your Health Plan

https://www.dmas.virginia.gov/for-members/
managed-care-programs/change-your-health-plan/

MEDICARE

https://www.medicare.gov/

Older Adults and Healthy Aging

https://www.cdc.gov/aging/olderadultsandhealthyaging/
index.html

PREVENTIVE CARE RECOMMENDATIONS FOR CHILDREN AND ADULTS:

https://www.uhc.com/content/dam/uhcdotcom/en/
HealthAndWellness/PDF/preventive-care-guidelines
_en.pdf

https://content.highmarkprc.com/Files/Region/PA/
EducationManuals/PreventiveHealthGuidelines/
pa-guidelines-19to64.pdf

Preventive Health Guidelines:

https://www.anthem.com/docs/public/inline/
17112VAMENBVA.pdf