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206-257-7780
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Click Here to Access Elation Passport Patient Portal
Please Review: Late Cancellation/ Reschedule and No- Show Policy
New Primary Care Patient Intake Form
April 4, 2023
/
Amna Mirza
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Date of Birth
*
Gender
*
Pronoun(s)
*
Phone Number
*
Email
*
Do we have your consent to send text, email and voice messages regarding your appointments?
*
Yes
No
Entire Home Address (Street Address Apt # City, State, Zip Code)
*
Please type in your FULL address above
Medical Insurance Name (INSURANCE PLANS NOT ACCEPTED – MOLINA (COMMERCIAL OR MEDICAID), AM BETTER/ COORDINATED CARE, UNITED HEALTHCARE (MEDICAID), 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.com
I do not have medical insurance. I will pay out of pocket
Note- This is REQUIRED to move forward with your request.
Which provider would you like to see?
Elizabeth Goldberg, ARNP (Membership)
Peter Grote, MD (Membership)
David Harvey, MD (Membership)
Margaret Loewen, ARNP
Megan Melo, MD
Kerri Orf, ARNP
Risa Cole, PMHNP (Mental Health ONLY)
Do Not Have A Preference
Reason for the Appointment Request
*
Visit Type
*
In Office visit
Telemed/Virtial Visit
No Preference
Are you looking for a new dentist for yourself or your child(s) in the Phinney neighborhood? Click yes to receive more information.
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