Patient Forms

New Patient Packet

This packet contains forms to register, transfer medical records, apply for the discount and also contains a copy of the RAHC Patient Rights and Responsibilities.  After the forms are completed please print the forms and either bring them to the office, fax the forms to 855-806-0826, or mail them to 25 Northridge Lane, Lexington, VA 24450.

Please fill out one form per patient. Children’s registration forms must be signed by a biological parent or legal custodian. Proof of custody may be required.

Complete Patient Registration form (includes medical and dental release of information)
Complete Patient Registration form with Support (for patients with no income source – includes medical and dental release of information)

Medical Patients

Dental Patients

Please fill out one Release of Record for each health provider you are currently seeing or have seen in the past.

RAHC offers a Sliding Fee Discount program to insured, uninsured, and underinsured patients based on annual income and family size under the U.S. Department of Health and Human Services annual Federal guidelines.  RAHC does not discriminate with regard to race, color, religion, national origin, age, gender, sexual orientation or disability.  No one will be denied access to services due to inability to pay.

Learn more here.


  • Instructions and Application Fee Discount Program here.
  • Statement of Support (for patients with no income) here.
  • Income Verification Form (for patients that do not receive pay stubs) here.
  • Self Employment Verification Form

Income Guidelines

Household SizeAnnual Income (200% FPL)
1 $25,520
2 $34,480
3 $43,440
4 $52,400
6 $70,320
7 $79,280
8 $88,240
Each add'l$8,960
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