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 Intel Connected Care, Kaiser CHP, Regence BCBS, PacificSource, Providence, MVA PIP (personal injury) 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.
Pricing is being updated to reflect a steady rate across all “out of pocket”/cash services. For non-checks and non-insurance patients, the rate is $2.89 per minute in session, until Jan 1, 2027. This website will be updated as time and ability allows. The Acuity scheduling calendar rates are current.
For more up-to-date information please read the Populace Wellness patients’ quarterly newsletter, which can be found here: Patients’ Quarterly Newsletter
