For all patients:
Please print, sign and date before your first appointment. Then email a PDF of this completed consent to treatment form and a copy of your photo ID to populacewellness@gmail.com, before your first appointment.
[Optional: There are also PDF filler apps available online if you don’t have printing access.]
Alternatively, you may also upload any relevant docs to the online scheduler, under your “patient history” section.
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For insurance patients including Kaiser CHP, Regence BCBS, PacificSource, Providence, MVA PIP auto accidents:
Please print and complete only the top “patient” section, which ends with a signature and date (lines 12 and 13). Then email a PDF of this completed claim form, the consent to treatment form, your insurance ID card and your photo ID to populacewellness@gmail.com, before your first appointment.
[Optional: There are also PDF filler apps available online if you don’t have printing access.]
Alternatively, you may also upload any relevant docs to the online scheduler, under your “patient history” section.
Populace Health Insurance Claim Form
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For Worker’s Compensation patients:
I’m sorry. Populace Wellness is not accepting Worker’s Comp. claims at this time.