Forms to Print

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. 

Informed Consent to Treatment

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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.