TriValley Primary Care - Information

On this page are topics that provide special information.

TriValley Primary Care - Guide for New Patients

Welcome to TriValley Primary Care! To make your first visit most productive for all concerned, the following guide is provided.

Note: You may complete the various forms prior to your visit by viewing our New Patient Forms section. It is recommended that you go to that section after reviewing the information here.

New Patient Guide

Please come to your first appointment 15 minutes early to complete the registration process. All adults that are new patients to the practice must bring photo identification (ID) on the first visit. A driver's license is preferred. A passport is acceptable. You'll need to furnish your social security number, too.

Each patient must complete a Patient Registration form. Each adult must complete and sign a Financial Responsibility form.

Provide your insurance card(s) to the receptionist. TriValley staff will scan or copy the card(s) for your file. Please plan on showing your insurance card(s) at each visit.

Note: If you have subscribed to an HMO plan, you must designate * a primary care provider to handle your care. Please telephone your insurance company (telephone number is on your insurance card) and give Customer/Member Service the name of your TriValley provider. Alternatively, you may give the TriValley office number for the physician you will see. The TriValley office numbers are listed on the Insurance Plans Accepted page on the Our Practice page. The numbers are also available via Doctor/Physician look-ups on your insurance plan's website. * There are exceptions in which a designation is not required.

Bring the containers (bottles) of the medications, supplements, herbals, and vitamins you are currently taking, including over the counter medications. These will be reviewed with you. Please let your physician know that you need a refill, as necessary. If you are currently taking a controlled substance, please be advised that you will be required to sign and adhere to a Controlled Substances Management Agreement.

Please come prepared to complete a form that details your past Medical History. This will ask dates of meaningful medical events, such as operations you've had. A separate form is available for children.

You are encouraged to read TriValley's (HIPAA) Notice of Privacy Practices. When finished, please complete the Acknowledgment of Receipt of Notice Form and bring it in with you.

Other matters: If you have an Advanced Directive (living will, durable power of attorney, or do not resuscitate [DNR] order), please bring it with you. Also, please bring a financial affairs power of attorney with you, if applicable, as well as any order/paperwork regarding custody/guardianship, etc. If your first visit is related to an injury sustained on the job or due to an automobile or other accident, please complete the appropriate WC or Auto form providing information from your employer or insurance agent, including claim number and the address to send the claim.

Request transfer of your records to your TriValley physician at least 2 weeks prior to your appointment, if possible. A form with your TriValley office's mailing address to request the records is provided on each office's home page (Locate your provider's office on the Our Providers page. Click on that provider's office. Then look for the Transfer Records tab. Download the Transfer In form).

Please be prepared to pay your insurance plan's deductible, co-payment and co-insurance at the time of service. If you are not covered by insurance or another payment plan, please be prepared to pay for the first visit. Cash and checks, and MasterCard, VISA, and Discover (NOVUS) are accepted. If you are unable to pay for your initial visit, and need to make payment arrangements, please contact the office before your scheduled appointment.

For Children:

In addition to the above, please bring your child's social security number and immunization record with you. Please complete the Minor Consent form for each child. Note: Children under 18 must be accompanied by a parent or legal guardian for their first visit.

New Patient Forms

You are requested to download, complete, print and sign these forms before your first visit. This will save you time after you check in with the receptionist.

Type and Tab: These forms are designed to be completed on your computer using Adobe Reader.* To complete a form, click on the form which will open it, then start by clicking your mouse pointer on the first field. Fields are in a color other than white. You may use the Tab key to move to the next field to be entered. The tabbing function is somewhat imprecise, so you may need to click into a field that the tabbing skips. Please review the information you entered, and print it by clicking on the Print Form button at the bottom of the form. Then sign the form(s), if applicable. Please hand the form(s) to the receptionist as you arrive.

* Note: Or, you may simply print the forms by clicking on the Print Form button at the bottom and complete them with a pen. Please print legibly. Then sign the form (if applicable).

Registration and Financial Forms

Patient Registration Form (complete this for each person, including each child)

Note: The name you enter must match how your insurance company has the name listed. Please check your insurance card and call the insurer's Customer Service (use the telephone number on the back of the card) to make corrections. The subscriber (employee) may need to do this.

Financial Responsibility Form (each adult must complete one of these)

Reminder: Adults will need to present insurance cards and photo identification (as a new patient to the practice) to the receptionist. If you have a power of attorney, please present this to the receptionist as well. Please plan on presenting your insurance cards at each visit.

If this first visit is related to an injury sustained on the job or due to an automobile or other casualty accident, please complete the applicable form, below.

HIPAA Privacy Form

Please review the TriValley's Notice of Privacy Practices, then complete this form:

Acknowledgment of Receipt of Notice Form

Note this form also allows you to designate other telephone numbers and persons who may take calls regarding your health information.

Medical History Form

Medical History Form (complete this for each adult)

Pediatric Medical History Form (complete this for each child)

Note that these forms have many fields to complete. These are prepared with Type and Tab capability — described above. You may have to click on a field if the tabbing skipped it. Please review the form carefully before printing.

Minor Consent Form

Please complete this form if you wish to authorize someone other than you (or spouse or legal guardian) to handle the health affairs of your child(ren).

Minor Consent Form (complete for each child that may be brought in by someone other than a parent or legal guardian)

Workers' Comp and Automobile Accident Forms

If applicable, please complete the appropriate form. On the job injuries must be reported to your employer in a timely manner. Please contact your agent or employer as needed to complete the form.

Workers' Compensation Data Worksheet Form (complete for injuries related to employment)
Automobile and Casualty Insurance Data Worksheet Form (complete for injuries related to an accident)

Controlled Substances Management Agreement Form

If you are currently taking a controlled substance you shall be required to sign and adhere to the provisions contained in the Controlled Substances Management Agreement.

Controlled Substances Management Agreement (complete if taking a controlled substance; but do NOT sign before speaking with your physician)

Transfer Records Form

A records transfer form with each office's mailing address filled in is available for your use. If you haven't yet transferred your records to your new TriValley provider's office, please locate your provider's office on the Our Providers page. Click on that provider's office. Then look for the Transfer Records tab. Please download the Transfer In form, complete it (these are Type and Tab capable) and mail it to the office of your former provider. Thank you for placing your trust in us!

Access to Documents on this Site
TriValley Primary Care relies on the Portable Document Format (PDF) to furnish most of the documents on this website to you. If you cannot access a PDF file by (double) clicking on it, please click here to obtain the latest version of Adobe Reader. (Adobe Reader will open PDF files.) Follow instructions to select the correct Reader for your operating system.

Update Information Forms

Please note: if you are a new patient, please see our Guide for New Patients tab, above.

The following forms are available to you to download, complete, print (and sign) as needed when your information changes. Provide the form(s) to the receptionist when you check in for your next appointment or feel free to leave them with a receptionist during office hours.

Type and Tab: These forms are designed to be completed on your computer using Adobe Reader.* To complete a form, click on the form which will open it, then start by clicking your mouse pointer on the first field. Fields are in a color other than white. You may use the Tab key to move to the next field to be entered. The tabbing function is somewhat imprecise, so you may need to click into a field that the tabbing skips. Please review the information you entered, and print it by clicking on the Print Form button at the bottom of the form. Then sign the form(s), if applicable.

* Note: or, you may simply print the forms by clicking on the Print Form button at the bottom and complete them with a pen. Please print legibly. Then sign the form (if applicable).

Registration and Financial Forms

Patient Registration Form (Enter name and date of birth, then enter any changed information)

Please write the word UPDATED in large lettering across the top of the form.

Note: The name you enter must match how your insurance company has the name listed. Please check your insurance card and call the insurer's Customer Service (use the telephone number on the back of the card) to make corrections. The subscriber (employee) may need to do this.

Financial Responsibility Form (Enter name and date of birth, then enter any changed information)

Please write the word UPDATED in large lettering across the top of the form.

Note: This form should be completed when a young person becomes an adult (age 18—even if covered by another person's policy) and when a patient becomes eligible for Medicare (age 65) or if you purchase a Medigap policy to supplement Medicare coverage.

Reminder: Adults will need to present insurance cards at each visit to the receptionist. If you have a power of attorney, please present this to the receptionist as well.

Email Consent Form (Provide or change email address or rescind consent to use email address)

Use this form to provide an email address for TriValley to contact you. It may also be used to change an email address or to rescind your consent to allow TriValley to use your email address.

Note: You must provide an email address in order to use TriValley's web portal (future service). The web portal provides a means to obtain clinical information and other messaging about your health quickly, as well as an automated means for you to provide updated information.

HIPAA Privacy Form

Acknowledgment of Receipt of Notice Form

Please write the word UPDATED in large lettering across the top of the form.

This form allows you to designate other telephone numbers and persons who may take calls regarding your health information. It is also used to authorize TriValley to use voice mail at a given telephone number and to name a Personal Representative. The form is provided for you to inform your provider as these elements change.

Medical History Form

Medical History Form (For adults: Update every 3 years—recommended)

Pediatric Medical History Form (For children. Update every 3 years—recommended)

Please write the word UPDATED in large lettering across the top of the form.

Note that these forms have many fields to complete. These are prepared with Type and Tab capability—described above. You may have to click on a field if the tabbing skipped it. Please review the form carefully before printing.

Minor Consent Form

Minor Consent Form (complete for each child that may be brought in by someone other than a parent or legal guardian)

Please write the word UPDATED in large lettering across the top of the form, if this is to replace a previous form. Complete this form if you wish to authorize someone other than you (or spouse or legal guardian) to handle the health affairs of your child(ren).

Workers' Comp and Automobile Accident Forms

If applicable, please complete the appropriate form. On the job injuries must be reported to your employer in a timely manner. Please contact your agent or employer as needed to complete the form.

Workers' Compensation Data Worksheet Form (complete for injuries related to employment)

Automobile and Casualty Insurance Data Worksheet Form (complete for injuries related to an accident)

Access to Documents on this Site

TriValley Primary Care relies on the Portable Document Format (PDF) to furnish most of the documents on this website to you. If you cannot access a PDF file by (double) clicking on it, please click here to obtain the latest version of Adobe Reader. (Adobe Reader will open PDF files.) Follow instructions to select the correct Reader for your operating system.

TriValley Primary Care — Advance Directive Guide

The following information regarding advanced directives is presented for your information. Medicare and some other health plans encourage their subscribers specifying their preferences in such matters in advance.

An advance directive is a document or documents informing your caregivers what type of care you would like to receive in the event you are unable to make a medical decision. A Living Will, a Do Not Resuscitate (DNR), and a Durable Power of Attorney (DPA) are types of advance directives.

A living will is a legal document that describes the type of medical treatments you would like to receive if you are or become terminally ill.

A DNR is an order to your physicians requesting they not perform any cardiopulmonary resuscitation if you stop breathing or your heart stops beating.

A durable power of attorney (DPA) declares who you would like to make medical decisions for you. It is only activated if you are unconscious or otherwise unable to make medical decisions for yourself.

You do not need an attorney to document your Advanced Directives, but your attorney should be made aware of your decisions.

The Commonwealth of Pennsylvania Department of Health has a document available for you to document your Advanced Directives. It details your rights and prerogatives as well as provides a means to prepare an advanced directive.

The Pennsylvania Medical Society has prepared a somewhat simpler advanced directive document for download as a sample for your use.

Your TriValley provider would like a copy of your advanced directive. You may mail it or bring it with you on your next visit.

FamilyDoctor.org is the main source of above information.

For additional information on advanced directives in Pennsylvania, please visit the Pennsylvania Medical Society's patient website.

Disclaimer

By clicking on the OK button below, you acknowledge and accept that:

  • The medical links and patient information provided on TriValley Primary Care's website are provided through independent sources, hereafter called THIRD PARTIES, which have no relationship of any kind, financial or otherwise, to TriValley Primary Care. This content is provided for your convenience and for informational purposes only. TriValley Primary Care does not endorse any of the products or services available through these THIRD PARTIES.
  • The information contained on TriValley Primary Care's Medical Links site is inherently limited in nature, may be inaccurate or incomplete, is subject to change without notice, and is continuously revised and updated. Furthermore, content provided by THIRD PARTIES is not medical advice and is not intended to be a substitute for professional medical advice, diagnosis or treatment. You should always seek professional medical advice before beginning any medical regimen, diet regimen, accelerated exercise program or any medication changes.
  • Neither THIRD PARTIES nor TriValley Primary Care assumes any responsibility for any circumstances arising out of the use, misuse, interpretation or application of any information or other material provided on or through TriValley Primary Care's Medical Links. This disclaimer supplements and does not replace THIRD PARTIES' own disclaimer, implied or expressed, which you are encouraged to review.

Disclaimer

 

 

Home     :     Mission Statement     :     Providers     :     TVPC FAQ     :     Contact     :     Non Discrimination

Copyright © 2016. All Rights Reserved