Patient Forms

As a convenience to our patients, BRFP offers patient registration through our Online Services. You can register through this link to complete and submit pre-registration forms ahead of your appointment. You may also use your On-line Services to request future appointments, referrals, and prescription refills.

Registration and insurance forms can also be downloaded, printed, completed and brought with you to your first appointment. Just click on the PDF forms below. If you have a change of insurance provider, you will need to prepare a new insurance form.

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Health Forms Policies

It is the goal of the physicians and staff to accommodate as many requests as possible to the furthest reasonable extent, bearing in mind the following limitations:

• Blank forms will not be accepted. Forms will only be accepted for completion if the patient’s name and other information have been completed. In some cases we may not be able to complete or certify a form if parents have not completed their parts of the forms prior to form submission.
• Turnaround time for form completion is usually fewer than 10 business days. While every effort will be made to complete forms as quickly as possible, please realize that at certain times of the year we may receive hundreds of health forms in one week. Each of these forms must be carefully reviewed by a physician before it is released. Parents are strongly advised not to wait until the last moment to review the paperwork they receive from the program their child is scheduled to attend.
• Forms are held at the office for pick up. The Health Insurance Portability and Accountability ACT (HIPAA) regulations require forms to be released only to the patient or parent/ guardian. Federal law prohibits doctors’ offices from faxing or mailing medical information to non-medical facilities. We are not responsible for delays or losses in the mail.
• Forms are completed for those whose accounts are in good standing. Delinquent accounts must be brought current before forms will be released. Forms must be paid for before they are released.
• Many forms require the information to be base, on an examination completed within 12 months of the date the form is completed. These requirements notwithstanding, no form will be completed for any patient who has not had a physical examination in our office in more than 24 months.
• Physical examination requires checks of perceptual ability, i.e., hearing and vision screening. We regret that we cannot certify a child fit for any program without appropriate perceptual (hearing and vision) testing.
• Forms completed are based on examinations conducted by physicians and nurse practitioners in this medical group. Your physician will not cosign examinations performed by another facility, nor will he or she complete any forms based in whole or in part on any information provided by other facilities.
• Completed forms are based on information abstracted by staff from your medical records. A physician for completeness and accuracy reviews all forms. In some cases, forms mandate that only the physician may complete them.
• Insurance companies do not reimburse for form completion, and we do not bill insurance for completing any form.
• Rush service may be available for an additional $75. If available, we will have your form completed in 2 business days. $30 for completion in less than 5 days. We do not guarantee the availability of this service.

NOTE: Staff members DO NOThave the authority to reduce or change charges.

School Forms – Blue Forms / Sports Physical Forms

The State of Virginia has specific physical exam requirements for children entering school and playing sports. Many daycare facilities also require documentation of a child’s health and immunization status.

Bull Run Family Practice will provide:

• One copy of your original form per exam at NO CHARGE
• Additional copies of these forms are $10 per copy
• An additional original is $25.00
  

These fees are to be paid prior to releasing the form and can be paid by cash, check or credit card.

Requests for mailing forms must be paid by Visa or Master Card at the time of the request.