TriValley Primary Care - Our Patient Services

On this page are topics that describe special TriValley patient services. In addition, there are means to request services, get forms, and to provide feedback. You are encouraged to explore these.

TriValley Primary Care - DEXA Bone Scan

DEXA Bone Scan Service
Offered by TriValley Primary Care

Osteoporosis and DEXA Bone Scans: What you need to know...

What is a DEXA scan?

It is a means of scanning your bones with low dose x-rays to determine their density and to measure bone loss. These measurements are used to diagnose osteoporosis and a patient’s risk of fracture. DEXA is the common acronym for dual-energy x-ray absorptiometry. (DXA is the official acronym).

A DEXA scan is a simple, painless procedure that may be performed in an office setting, using a specialized device called a DEXA machine. TriValley has a DEXA machine in our Franconia Office in Telford. The patient reclines on a table that is part of the device. The scanning takes place by a movable component. The DEXA machine is operated by a Registered Radiologic Technologist and the results are reviewed by a physician. DEXA scans at TriValley are reviewed by Kelly Rose, M.D. who has had special training for this purpose.

What is Osteoporosis?

Osteoporosis is a disease of the skeleton where bones become weak due to bone tissue loss and therefore become more susceptible to fractures or breaks. Osteoporosis, left untreated, can progress silently and painlessly until the patient experiences a fracture.

Many patients may not be diagnosed with osteoporosis until they break a bone, often resulting from a minor fall or simple action such as sneezing. Vertebral fractures can be less obvious and cause symptoms such as back pain, loss of height and stooped posture.

Who is at risk for developing Osteoporosis?

Currently, it is estimated that 10 million individuals in the United States currently suffer from osteoporosis. Eighty percent of those affected are female. Some individuals are at greater risk for developing osteoporosis. They include:

  • Post menopausal women
  • A family history of osteoporosis
  • Caucasian and Asian ethnicity
  • People with a history of fractures
  • Pre-menopausal women who do not menstruate (amenorrhea)
  • Men over age 70
  • Those with diets low in calcium or vitamin D
  • People with an inactive lifestyle
  • Those who smoke or abuse alcohol
  • People using certain medications, including steroids
  • Those with a loss of height.

What do I do if I have Osteoporosis?

The good news is that your physician can help you treat osteoporosis so that a fracture is less likely to affect your life. You can change dietary and lifestyle behaviors to help improve your bone health, including taking calcium and vitamin D and exercising. Your physician can discuss these options with you. In addition, several prescription medications are now available that can help prevent and treat osteoporosis and related fractures. Your physician can use the results of your bone density evaluation to help develop a treatment plan that best meets your needs.

Vertebral Fracture Assessment

TriValley Primary Care will also perform a Vertebral Fracture Assessment (VFA) with your DEXA exam. The VFA is a low-dose x-ray exam of your spine, performed on the DEXA machine. This exam screens for fractures of the vertebrae. VFA exams are recommended for adults who have lost more than an inch of height or who have unexplained back pain. The VFA only adds a few minutes to the DEXA exam, and is performed on all patients.

How should I prepare for my DEXA scan? And, how long does the scan take?

Patients may eat and drink normally before their scan. However, patients should not take calcium supplements for at least 24 hours prior to the exam.

Patients should arrive wearing loose, comfortable clothing, free of metal zippers, belts, or buttons. You may be asked to remove eye glasses, jewelry, and any other metal objects that may interfere with the DEXA scan.

Patients should inform the Technologist if they recently had a barium exam or have been injected with contrast for any other radiologic testing.

The actual DEXA scan only takes 10-15 minutes after the patient is positioned on the table. However, please arrive 15 minutes before the exam for check-in (very brief), and allow 30-45 minutes to get in, get positioned, have the scan and then get yourself together after the exam.

Will my insurance company cover my DEXA scan at TriValley Primary Care?

TriValley Primary Care can submit claims for DEXA scans to Medicare. Medicare will cover DEXA scans for patients at risk for osteoporosis, including post-menopausal women and certain men who may also be at risk for osteoporosis. Medicare will reimburse TriValley Primary Care at 80% of their allowable amount, subject to the patient’s annual deductible. Certain secondary insurances may cover the remaining balance. Please contact your insurance company for details regarding your specific coverage.

In addition to Medicare, TriValley can also submit claims to Private Fee For Service (PFFS) Medicare plans that we participate with. These include Blue Shield Freedom Blue PFFS, Aetna Medicare PFFS and Blue Cross/Blue Shield Select Advantage PFFS.

Due to HMO referral rules, TriValley Primary Care cannot submit claims for DEXA scans to any HMO insurance. This includes so-called Medicare HMO plans such as Keystone 65 and Aetna Medicare HMO plans.

Do I need to be a TriValley Primary Care patient to have my DEXA scan performed at TriValley Primary Care, Franconia Office?

Yes, at this time, we are only performing DEXA scans on TriValley Primary Care patients.

How do I schedule my DEXA scan with TriValley Primary Care?

Inform your TriValley Primary Care physician or nurse practitioner that you are interested in getting a DEXA scan. If found medically suitable, your TriValley provider will prepare a referral for DEXA scanning. The office staff at any TriValley office can schedule an exam for you. TriValley Primary Care performs DEXA scans on Wednesday mornings and Thursday afternoons at our Franconia Office.

Contact us at:

TriValley Primary Care, Franconia Office
211 Telford Pike
Telford, PA 18969
(215) 723-7833

Directions to TriValley Primary Care, Franconia Office

From the Intersection of Route 63 & Route 113, Harleysville:
Go North (East) on Route 113. At the fourth traffic light, make a left turn onto Cowpath Road. Turn left at the first traffic light onto Telford Pike. Turn right into Indian Valley Shopping Center, where the office is located.

From Route 309:
Exit at the Souderton Exit, Route 113.
Drive South (West) on Route 113, following Route 113 through downtown Souderton (approx 4 miles). At the fifth traffic light, make a right turn onto Cowpath Road. Turn left at the first traffic light onto Telford Pike. Turn right into Indian Valley Shopping Center, where the office is located.

For more information on bone loss, these websites are recommended:

www.radiologyinfo.org and www.nof.org

Information for this feature was obtained in part from the National Osteoporosis Foundation and the Radiological Society of North America.

Travel Medicine

A service offered by Phyllis Shuhler, M.D. and TriValley Primary Care

1. What is travel medicine and who would be referred for a travel medicine consultation?

Travel medicine is for any person traveling to foreign countries where they may be exposed to parasites or diseases not commonly found in the United States of America. Of particular interest would be people traveling to under developed countries such as Africa, Southeast Asia, South or Central America, as well as rural Mexico.

Travel medicine includes treatment to prevent travel-associated illnesses such as deep vein thrombosis (DVT), insomnia, jet lag, mountain sickness, motion sickness, as well as advise regarding foods, beverages, bug sprays and sunscreens. Depending on where you are traveling, malaria pills or shots to prevent various illnesses such as Typhoid, Hepatitis A and Yellow Fever may be required. Depending on which part of the world you may be traveling, insect borne diseases can be of major concern and will be discussed. A plan of preventive care will be presented to you during your consultation.

2. Who would I contact for a travel consultation?

Phyllis M. Shuhler, M.D., TriValley Primary Care, Upper Perkiomen Office, performs the travel consultations. Dr. Shuhler completed Fellowship training at University of London’s School of Tropical Medicine and Hygiene. She is a member of the Royal Society of Tropical Medicine and Hygiene. She remains current in her continued medical education through this program. Dr. Shuhler worked in Ghana, West Africa, for three months in 1975 and again for a year in 1980-1981.

An appointment with Dr. Shuhler can be scheduled through our Upper Perkiomen Office by calling (215) 679-9321. She recommends that you contact the office as soon as your travel arrangements are made.

If several vaccines are required, Dr. Shuhler recommends that your visit be scheduled 2-3 months prior to your departure. It is usually a one-time office visit during which a plan of action can be set-up that could be followed by your personal private physician’s office. It is imperative that you schedule an appointment at least two weeks prior to your departure to ensure that you have adequate protection from possible illnesses, as it will take two weeks for some vaccines to become effective.

If your appointment cannot be scheduled during Dr. Shuhler’s regular office hours, special arrangements may be made to accommodate your needs.

3. What is included in a travel consultation?

Dr. Shuhler will review your past medical history and current medications to ensure that there are no interactions or risks while out of the country. She will advise you on what vaccines you need prior to your departure, as well as what medications you should take to prevent illnesses while traveling.

4. What are the costs for a travel consultation?

Dr. Shuhler does charge for her consultation, time and expertise. Unfortunately, most insurance companies do not offer coverage for this preventive care or the vaccines required for travel.

Vaccine prices are variable depending on the costs to our office. Adult Diphtheria Tetanus (DT) is strongly recommended, especially the Diphtheria part, as well as Inactivated Polio Vaccine (IPV). If your private doctor does pediatric care, they should have those vaccines available.

Other recommended vaccines, depending on your place of travel include Yellow Fever, Hepatitis A, and Typhoid. Hepatitis B vaccine is recommended for people working with sanitation or in the Healthcare field. Hepatitis B is a series of three (3) vaccinations.

The cost of Malaria medications varies. This medication is dependent on the resistance of malaria in your chosen country and any medical conditions you may have. Dr. Shuhler will provide a written prescription for the malaria medication that can be obtained at Professional Pharmacy in Pennsburg, (215) 679-9700.

If you prefer to use your own pharmacy or pharmacy plan for the malaria or any of the needed medication or vaccines, Dr. Shuhler would provide a prescription to take to your personal pharmacist. Please allow extra time for them to get the medications, as it is not a routine prescription they would typically have in stock.

5. Where can I find additional information on Travel Medicine?

Additional information regarding travel medicine may be obtained from Executive Health Services, Travel Vaccine Clinic at the Philadelphia Art Museum office at 1-800-ASPIRIN.

In summary, a travel consultation is strongly recommended for anyone going into an area of development, especially in Africa, South or Central America and the Far East. If you have future travel plans overseas and feel that you would benefit from a consultation, please do not hesitate to call (215) 679-9321 to schedule an appointment with Dr. Shuhler.

Phyllis M. Shuhler, M.D.
TriValley Primary Care
Upper Perkiomen Office
101 W. 7th Street, Ste. 2C
Pennsburg, PA 18073

Phone: 215-679-9321

Patient Portal Links

Established Patient of the practice:

Established patients of TriValley Primary Care are invited to review the Patient Portal Guide section if you have just received your user name and password for access to the Patient Portal, or if you are considering asking to be enabled on the Patient Portal. This is a good summary of what to expect.

If you are an experienced user of the Patient Portal, you may use this link to access TriValley's Patient Portal:

Forgot your password? Click here to get step by step instructions to reset your password.

Portal Help: For help with all other aspects of the Patient Portal, click here to connect to the help pages website. No portal login is required. This site also shows the various types of features available via TriValley's Patient Portal. Click on topics in the left-hand pane. Detailed explanations will appear in the right-hand pane.

New (prospective) Patient:

New (prospective) patients to TriValley Primary Care have the ability to pre-register with the practice before their first visit. They are strongly urged to review the Patient Portal Guide section before doing so. Established patients should NOT use the link below to obtain a user name and password. Instead, established patients should request to be enabled on the Patient Portal at their next visit.

If you are a new (prospective) patient to TriValley, you may use the following link to pre-register prior to your first visit. Please telephone your TriValley office and inform them that you have pre-registered. (There isn't yet a means to record your TriValley office preference via this link. Your phone call will alert your TriValley office to look for your pre-registration information.)

Patient Portal Guide

The Patient Portal is a secure means for a TriValley patient to view and print significant portions of his/her health care information from any place with internet access. And, the TriValley patient has the ability to update select items of information affecting his/her care, treatment, condition or demographics and financial information.

Prerequisites: To use the Patient Portal each patient must have internet access and an email account. Internet access is necessary to access the Patient Portal, while email is used to notify a TriValley patient that new information has been posted to the Patient Portal.

Internet access is widely available, including free service at public libraries, book stores and coffee shops. Email service too is widely available with free service available from several sources including Google.com and Yahoo.com to name two. Two key things to remember and record: How to access the email service (the internet/web address) and your user name and password for that service. It is recommended that you write these down and keep this where you can readily access it — including while traveling.

Privacy: With the Patient Portal, nothing about your care, treatment or condition is revealed in an email. Email is used to notify the patient that new information is available on the Patient Portal. Email is also used to notify a TriValley patient of an upcoming appointment, much like TriValley's telephone reminder service. Access on the internet is provided by a secure connection, with each patient having a unique user name and a personal password. Therefore, patients may share an email address but only the patient may log in and read his or her private health care information.

Patient Portal Services and Features: All of the features/services listed below are available now. TriValley Primary Care will add other services and features as they become available.

Through the Portal the PATIENT may:

  • request prescription refills from the medication list on file
  • request referrals
  • request appointments for routine follow-up, a physical or a Pap exam
  • request new laboratory testing
  • update your demographics (new address, phone number, etc. )
  • add certain elements of your medical history (for example, Family History)
  • add immunization records
  • send a NON-URGENT message to the office
  • - view / print Patient Summaries (a visit summary) of each of your visits
  • - view / print your Personal Health Record (PHR)
  • - view your lab and diagnostic imaging results
  • - view upcoming and past appointments (appointment history)
  • - view your account statements

Through the Portal your DOCTOR may:

  • send your test results for your personal viewing with directions and comments
  • send messages and reminders regarding your health care
  • import information submitted by you to your electronic medical record
  • send appointment reminders

Note: For now, please use the Pay a Bill feature on the TriValley website to make a payment on an account This feature may be available on the Patient Portal in the future.

Obtaining Access to the Patient Portal: Please inform the receptionist that you want the Patient Portal enabled and provide an email address. ("I want access to the Patient Portal") It is that simple.

If you wish to request access to the Patient Portal for your children (parents are encouraged to do so), you may share an email address, but each child will get his/her own user name and (temporary) password.

To be enabled for this service, TriValley Primary Care will give you a User Name and Temporary Password and direct you to the Portal address:

Upon initial log in, you will be directed to answer two security questions and will be directed to change your password to something only you will know.

Reminder: No private health care information will ever be sent to you by email. If TriValley Primary Care puts anything on the Patient Portal, you will receive an email informing you to log on to the Patient Portal to retrieve the message. The sender of the notice will be reminders@eclinicalmail.com Please add this sender as a Safe Sender, Not Junk, a contact in your email address book or the equivalent in your email reader application.

Getting started: To get started, please make sure our staff has your current email address and add reminders@eclinicalmail.com to your approved email senders list or to your email address book.

Mobile Device Access: The TriValley Patient portal is accessible from your mobile devices via the healow app. When you log into your Patient Portal account, you will see a link to add the healow app. If that is not available, you may go to www.healow.com or search for healow in the iTunes App Store (or the equivalent for your device operating system). The healow app provides most of the features of the Patient Portal, but offers a few more, such as medication reminder messages!

Responsibility: Patients enabled for the Patient Portal are responsible for logging in when they receive an email that new information has been provided. Failure to access the Patient Portal when notified is grounds for TriValley to suspend and deny access.

Ability to Terminate Access: You may end your access to the Patient Portal at any time. Just notify the receptionist at your next visit, or you may mail a request to the office saying that you want your access to end. (For security purposes, if you are not present, a written request is needed.)

Email Address Changes: If your email address changes, please provide your new email address to the receptionist so that the Patient Portal remains available to you.

New (Prospective) Patients: Anyone intending to become a TriValley patient has the ability to pre-register prior to the first visit. Pre-registration has several benefits including assurance that the person's name, address and insurance information, among other data elements, are recorded correctly, and faster registration at the first visit. Another significant benefit is that the prospective patient will obtain access to the Patient Portal. With Patient Portal access, medical information, such as Family History and immunization history may be provided prior to the first visit, which helps the physician understand your health status and condition.

TriValley Primary Care is excited to offer our patients this robust service! Request access to the Patient Portal at your next visit. Your doctor will be pleased that you did, and before long, so will you!

Lower Salford Laser

This link will navigate away from www.trivalleypc.com:

http://www.lowersalfordlaser.com/

Request Prescription Refill

Prescription refills may be requested online via the Patient Portal. See the Patient Portal tab.
Further information and other options are listed on the Prescription Renewals tab for your TriValley office as listed on the Our Practice page.

Request a Referral

Referrals may be requested online via the Patient Portal. See the Patient Portal tab.
Further information and other options are listed on the Referrals for Care tab for your TriValley office as listed on the Our Practice page.

Request Appointment

Appointments may be requested online via the Patient Portal. See the Patient Portal tab.
Further information and other options are listed on the Appointments tab for your TriValley office as listed on the Our Practice page.

Pay a Bill

This link takes you to a secure page for making payments online:

Pay a Bill Service

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. There you may download forms individually or download all forms at one time that a new patient needs. It is recommended that you go to the New Patient Forms section after reviewing the information here. In addition, you may download these forms from the Patient Portal, if you have access (recommended – See the Patient Portal tab, above).

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.

Forms Packet Downloads

Below are links to download in one packet the various forms that a new patient needs. Included is a checklist to assist you in preparing for your first appointment. Note: You may complete these forms and mail them to, or drop them off at your TriValley office prior to your appointment.

Adult Forms Packet

Pediatric Forms Packet

You are encouraged to review the instructions for these forms below.

First Appointment Checklist

A checklist is included in the packets of forms links above. You may download it separately here.

First Appointment Checklist

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.

Patient Centered Medical Home

Patient Centered Medical Home - Recognized Practice

Patient Centered Medical Home (PCMH) is a model of care that ensures the patient’s care is coordinated, so that treatment is always rendered with regard to the whole patient.  PCMH recognition is obtained through a process of evaluating standard treatment practices by the physicians and other health care providers. Patient Centered Medical Home Recognition is awarded by the National Committee for Quality Assurance, via its Physician Practice Connections and Patient Centered Medical Home Recognition Program.

Through the dedication to patient quality care of the TriValley owners, each TriValley Primary Care office has been awarded the highest level of PCMH recognition. The date in the emblem above indicates the year in which the standards were set that TriValley offices met.

The principles of a medical home are outlined in a joint statement by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association, which was published in 2007.

These Joint Principles include:

  1. A personal physician: each patient in our practice is assigned a primary care physician, who coordinates that patient's care.
  2. Physician directed medical practice: the personal physician leads his or her team of professionals who collectively manage the patients’ care.
  3. Whole person orientation: a medical home is responsible for the whole patient, coordinating care for all stages of life. Whether the patient is being seen for acute, chronic, or end of life care, the personal physician collaborates with all caregivers so that the patient’s care is directed to the whole patient, rather than individual symptoms or diseases.
  4. Care is coordinated/integrated: a medical home follows patients through the health care system, coordinating care with hospitals, specialists, home health agencies, and nursing homes. This ensures the patient does not encounter any lapses in care, and improves patient outcomes. Patients can expect their care to be coordinated across practices, so that if the personal physician refers the patient to a specialist, they are also coordinating care with that specialist through an exchange of clinical information.
  5. Quality and safety: a medical home strives to achieve the highest quality of care with defined clinical quality outcomes backed by evidence-based medicine. Patients can expect their personal physician to monitor their progress towards these clinical quality measures and work together to achieve the best possible outcomes.
  6. Enhanced access: medical homes must be accessible to patients with same-day appointments and electronic communication capabilities, such as those our patients will find on the patient portal. Payment: medical homes will be properly reimbursed by insurance companies in recognition of the added value patients are receiving.

TriValley Primary Care physicians endorse, recognize and adhere to the principles outlined above, and underwent a rigorous recognition process to attest to their adherence.

Through participation in, and adherence to, such programs as Patient Centered Medical Home, our patients should expect to receive the highest level of quality medical care when they seek treatment with a TriValley Primary Care provider.

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 and PRINT 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 Agreement - Comment or Suggestion Form

TriValley Primary Care is providing the means for you to provide your comments and suggestions via this on-line link. This is intended to be an easy means to do this. So that this may be a good experience for all concerned, there are rules to follow. To proceed further, you must agree to the following rules:

  1. I agree to read the instructions on the comment form. In particular, I will carefully review the purpose and limitations statements on the form.
  2. I understand and agree that the comment form is NOT to be used as a means of dialog (two-way contact) with a TriValley physician or office, but rather to convey my thoughts on how the practice may be improved or recite my experience with TriValley staff, a provider, policy, or process. If I need to speak with a physician or nurse, I will call the office.
  3. I understand that this link is NOT to be used to ask a question. I will direct my questions to the medical office I visit or the TriValley Corporate office by means of telephone or U.S. postal service mail or in person as appropriate.
  4. I agree that I will NOT use this form to request services of any kind, but especially those that need immediate attention or where my health may be jeopardized by a delay.
  5. I understand that should I make a suggestion, I do so with no expectation of compensation or other remuneration, or for special treatment of any kind. I acknowledge that no compensation or special treatment will be forthcoming. Furthermore, I understand that TriValley has no obligation to give my suggestion any more than cursory consideration.
  6. I understand that my comment or suggestion may not be acknowledged. If I desire a response, I will call the office. If it is an urgent matter or an emergency, I agree to seek care at the most immediately available medical facility, including a hospital emergency room or I shall call 911, as appropriate.
  7. Special Notice: I understand that this form may NOT be used to make an allegation of serious wrong-doing (criminal or civil) by a TriValley provider or staff member. However, I may use this link (Contact Risk Manager) to file a report regarding an alleged serious or illegal action or criminal activity.

Having read and understanding all of the above, I agree to use the form for the stated purposes as shown on the form. By clicking the "I Agree" button, below, I affirm my intention to abide by the above rules.

TriValley Primary Care

QuikMedsSM Program

QuikMedsSM is TriValley's answer to higher co-payments for drug card use and drug costs. What is  QuikMedsSM?

QuikMedsSM is a cash and carry generic drug program, that is, pre-packaged generic drugs that you can purchase and take with you from this office.  QuikMedsSM are reasonably priced – lower than most prescription plan co-payments.

  • Cash, check and credit cards are accepted.
  • No insurance plans will be billed.

If interested, please ask your TriValley provider if your medications are available via QuikMedsSM.

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

Controlled Substances

TriValley Primary Care in an effort to manage chronic conditions more effectively is enacting a Controlled Substances Management Agreement between doctor and patient on new and long term prescriptions classified as controlled substances. Please read it carefully. Failure to adhere to the terms of the agreement include dismissal from the practice.

Please use the Type and Tab feature described below to complete the form, but DO NOT SIGN THE FORM UNTIL YOU HAVE DISCUSSED THIS WITH YOUR PHYSICIAN.

Type and Tab: This agreement is designed to be completed on your computer using Adobe Reader.* Click on the agreement to open it, then start by clicking your mouse pointer on the first field. You may use the Tab key to move to the next field to be entered. Please review the information you entered, and print it by clicking on the Print Form button at the bottom of the agreement. Please hand the agreement to the receptionist as you arrive. Do NOT sign the agreement until your appointment.

* Note: Or, you may simply print the agreement by clicking on the Print Form button at the bottom and complete it with a pen. Please print legibly.

Controlled Substances Management Agreement

If you do not have Adobe Reader installed, click here to get the latest version.

 

 

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