Policies and Forms

Confidentiality and Privacy:

Your medical record is strictly private. Our office and staff are compliant with HIPAA privacy standards, and we will treat your protected health information according to the law and consistent with our (Notice of Privacy Practices).  We will not give out information regarding your condition to your employer, friends, or relatives without your written consent. The only exception to this is when required by law as in industrial injuries, assaults, risk of harm to self or others, or when we have received a valid subpoena for medical records in a legal proceeding. 

Additional Information:

Please click on the titles below for more information and access to specific form downloads.

>> Telephone Calls:

All patients are encouraged to call with any questions they have regarding medical problems. We try to be available for phone calls, however, there may be times when you are asked to be placed on a short hold or you may be prompted to leave a voicemail.  Our office staff has been trained to answer many of your questions, however messages will be forwarded to your doctor if your request requires further consideration by a physician or nurse. Our nurses and doctors are working hard each day to take care of the needs of all of our patients.  We ask for your consideration and patience as there may be up to a 24 hour delay in response. When you call our regular office phone line numbe(540) 364-1581, if you hear a voicemail message please pay close attention to the menu options to forward your message to the appropriate staff member. 

>> Prescription Refills:

If you are calling for a prescription refill, we will ask you to call your pharmacy first so that this request can be electronically handled between the pharmacy and our office.  If you are completely out of your medication and our office is closed, your pharmacist can request a short-term emergency refill to fill your medication until the office opens under normal business hours.  Under no circumstances will narcotics be refilled nor prescribed without a doctor’s face to face appointment, per state and federal regulations.

>> Controlled Substances/Narcotics:

All prescriptions for controlled substances require a face-to-face encounter in the office with only your treating doctor.  It is our strict policy that there will be no refills of controlled substances called-in over the phone or by an after-hours physician when the office is closed.

When it is medically necessary for our doctors to treat you with a controlled substance, we abide by all local, state and federal regulations.   You may be asked to review and sign a controlled substance contract (see link below) when your medical condition(s) warrant ongoing treatment with controlled substances.  Compliance with your controlled substance contract is not optional, and violation of this policy may result in termination of medication therapy and/or your removal as a patient at Countryside Family Practice.

You are specifically consenting that you agree to any request for prescription monitoring by your physician or physician’s office, to include random urine or blood drug testing (at your expense), or pill counts.  Narcotic prescriptions will be monitored by the Virginia Board of Medicine Prescription Monitoring Program, which does share information with other states.  You are granting your treating physician permission to discuss your use of controlled substances with other physicians, pharmacists, or health care professionals who are part of your treatment team, subject to rules and regulations for HIPAA compliance.  Countryside Family Practice reserves the right to notify law enforcement, including local, state and federal agencies, as it applies to discovery of any suspicious or illegal behaviors identified as it pertains to use and abuse of controlled substances.

(Controlled Substances Contract)

>> New Patient Appointments and Forms:

New patient appointments:

We are accepting new patients on a regular basis.  We have no age restrictions of any kind.  As a family practice office, it is our intention and our pleasure to take care of whole families, including newborns and children.  When you are admitted to a local hospital, the hospitalist doctors or pediatricians at that facility will take care of you while you are in that hospital.  We work directly with all hospital systems and doctors in our region to ensure a smooth transition of your care from the hospital setting to our outpatient-only office setting.  All of our doctors are Board Certified in Family Medicine to take care of patients of all ages.  If you would like to establish care with one of our doctors, please review the office information tab on this website to include: hours, directions, insurance and billing information.  When you call our office to book your appointment, please indicate that you are a new patient to our office so that we may guide you on what you need to bring for your first visit.  For your convenience, we have included links for our new patient paperwork and we kindly request that you print and complete each of the forms prior to your first visit with us.  We look forward to caring for you and your family members!

(New patient forms)

(Adult History and Physical Questionnaire)

(Notice of Privacy Practices)

(Medical Records Release Form)

>> Appointments:

Appointments:

We see patients on an appointment basis, but we have same-day slots reserved for seeing you when an injury or illness occurs.  Please call as early as possible after our phone lines open at 7:30 AM each morning if you would like an appointment to be seen the same day.  We will make every effort to accommodate your request.  When scheduling appointments, please inform us of the nature of your visit, (i.e. illness, chronic problems, physical examinations, or consultation) so that we may book you the appropriate time slot for your exam.  If you need to cancel an appointment, please give the office at least 24 hours notice to avoid a no-show fee.

Appointments for Minors and Children:

Any child under 18 must either be accompanied by a parent or guardian, or possess a written note granting us permission to treat in the absence of a parent.  Please complete a Permission to Treat a Minor form below if this applies to your family situation.   Financial responsibility for the services provided will be to the parent/guardian of the minor.  According to Virginia Code § 54.1-2969, a minor shall be deemed an adult for the purpose of consenting to medical or health services needed in the care of:

•A need to determine the presence of or to treat venereal disease or any infectious or contagious disease that the State Board of Health requires to be reported;

•Birth control, pregnancy or family planning except for the purposes of sexual sterilization;

•Outpatient care, treatment or rehabilitation for substance abuse as defined in § 37.2-100; or

•Outpatient care, treatment or rehabilitation for mental illness or emotional disturbance.

(Permission to Treat a Minor)

>> Late-Show and No-Show Fees:

Late-Show and No-Show Fees:

Your doctor may require you to reschedule an appointment if you are more than 15 minutes late; you may be assessed a “no-show” fee of $40 dollars for office visits (15-minute slots) and $75 dollars for extended appointment/physical exam slots (30-minute slots).

We do realize that unexpected delays occur; if you have the opportunity to call us and let us know you are running late, we will discuss options with you at that point.  In many instances, our doctors may agree to see you when they have time between or after patients who have shown up at their normally scheduled appointment times – we ask for your understanding of this policy so that we can deliver the best service to our patients at all times.  We ask that you cancel or reschedule an appointment within 24 hours of the appointment time to avoid No-Show fees.  If you realize you have mistakenly missed an appointment, please call us at your earliest convenience so that we may reschedule you into a new appointment slot.

Billing and Insurance: 

>> Please click here for further information related to fees and payment.

Medical Records and Referrals

>> Please click here for information on specialists, medical records, and authorizations.