Category: Patient Resources

Patient Forms

Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.

Patient Forms & Helpful Links

Patient Forms

The following are some forms you may find useful.

New Patient Request Form

Health Risk Assessment

Patients who are coming for a Medicare Wellness Exam should complete this form and bring it with them to their appointment.

Direct Primary Care Intake Form

Patients who are new to our Employer Direct Primary Care program should complete this form and bring it with them to their first appointment along with their photo ID, DPC member card, insurance card, and any prescriptions, over-the-counter medications, vitamins and supplements they are taking.

Diagnostic Center Ultrasound Preparations

Patients who are coming for an ultrasound should review this form in advance, as certain exams require specific preparations.

Links

The following links may offer some useful information to help you make decisions regarding your family health and wellness. Always contact your provider if you have a question about your health care, or about any treatment options available to you. While the Internet is a valuable resource for information, your provider knows you and your family and combines that for a fuller understanding of the facts when determining your treatment options.

External Content Disclaimer

*Please note that pages of this site may be linked to other websites, which may have different terms of use and privacy practices than Privia Medical Group. Privia does not own, control, manage, supervise, direct, or otherwise have involvement in such other websites or the content of such websites. Privia is not responsible for the content of any linked websites. Privia is not acting as an agent for these websites, nor does Privia endorse or guarantee, in any way, their websites, content, or products. Privia makes no representation or warranty regarding the accuracy of information contained in linked websites, takes no responsibility for the use of copyrighted or otherwise protected materials on such linked websites, and has no control over the privacy practices or use of user information at such linked websites.

Insurance & Fees

We participate with the following insurance plans: Aetna (No HMO Plans), Anthem, Cigna, Humana Medicare (No Commercial Plans), Medicare, Medicaid (Virginia Premier & Anthem Healthkeepers Plus), Piedmont Community Health Plan, Coventry Health Care (No Medicaid), United HealthCare, OptimaHealth (No Medicaid), WebTPA – Custom Ink.

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Please bring your insurance card and your ID to each appointment so that we can confirm that we have the most up to date information in our records. That will ensure your claims are filed properly for you.

Many insurance plans require that you make a co-payment at the time of your visit. To make it as easy as possible for you, we accept cash, checks, and most major credit cards at our offices.

Should you have any questions about your insurance coverage, or whether a service or procedure is covered, please contact our billing and insurance department and they will be happy to assist you. You may reach them Monday through Friday, between 8:30 am and 5:00 pm.

Become a Patient

Patient Forms

The following are some forms you may find useful.

New Patient Request Form

Health Risk Assessment

Patients who are coming for a Medicare Wellness Exam should complete this form and bring it with them to their appointment.

Direct Primary Care Intake Form

Patients who are new to our Employer Direct Primary Care program should complete this form and bring it with them to their first appointment along with their photo ID, DPC member card, insurance card, and any prescriptions, over-the-counter medications, vitamins and supplements they are taking.

Diagnostic Center Ultrasound Preparations

Patients who are coming for an ultrasound should review this form in advance, as certain exams require specific preparations.

In-House Record Transfer Form

This form is used to ask one of our offices to send your records to another one of our offices.