New Patient Request Form – Phinney Primary Care & Wellness

Name

First

Last

Preferred Name

Date of Birth

Gender assigned at birth

Preferred Pronouns

Phone

Email

Do we have your consent to send text, email and voice messages regarding your appointments?

Do we have your consent to email you sensitive medical information, including your lab results, referrals, and lab orders from our HIPPA - Secure email address?

Address

Address Line 1

Address Line 2

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)

Insurance Group # (if none type in NA)

Insurance ID (with Prefix)

Insurance Card (front)

Drag & Drop Files, Choose Files to Upload

Insurance Card (back)

Drag & Drop Files, Choose Files to Upload

Primary Subscriber's First & Last Name - Medical Insurance

Primary Subscriber's Date of Birth

had Insurance type

Which provider would you like to see?

Heike Nuhsbaum ARNP
Peter Grote MD
Do not have a preference

Have 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

Phinney Primary Care & Wellness

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