New Primary Care Patient Request Form Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth *Gender *Pronoun(s) *Phone Number *Email *Do we have your consent to send text, email and voice messages regarding your appointments? *YesNoDo we have your consent to email you sensitive medical information, including your lab results, referrals, and lab orders from our HIPPA – Secure email address? *YesNoHome Address – Street Address, Apt # *Please type in your FULL address aboveHome Address – City, State, Zip Code *Emergency Contact: First and Last Name *Emergency Contact: Relationship and Phone Number *Medical Insurance Name (INSURANCE PLANS NOT ACCEPTED – CIGNA, MOLINA, AM BETTER/ COORDINATED CARE, UNITED HEALTHCARE, PREMERA HMOs, MEDICARE, PREMERA MEDICARE ADVANTAGE PLAN, HUMANA) *PLEASE EMAIL US A PICTURE OF THE FRONT & BACK OF YOUR MEDICAL INSURANCE CARD AT FRONTDESK@PHINNEYPCW.COM Insurance ID (with Prefix) *Insurance Group # (if none type in NA) *Primary Subscriber's First & Last Name – Medical Insurance *Primary Subscriber's Date of Birth *Email pictures of medical insurance card to frontdesk@phinneypcw.com *I have emailed pictures (front & back) of my insurance card(s) to frontdesk@phinneypcw.comI do not have medical insurance. I will pay out of pocketNote- This is REQUIRED to move forward with your request. Which provider would you like to see? *Heike Nuhsbaum MSN, ANP-BC (Scheduling New Patient Visits in October 2026)Kerri Dansby ARNP (Membership Required)Do Not Have A PreferenceHave you had an annual wellness exam / check up in the past 12 months? (Medical Insurance covers 1 wellness exam every 365 days) *Were you referred by someone? If so, by who (name)? *Reason for the Appointment Request. For example – Med Management, Chronic Illness, Wellness Exam etc (Establish care is not a reason) *Preferred Pharmacy – Name and Address *Submit
