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.

Alternatively, you may also upload any relevant docs to the online scheduler, under your “patient history” section. 

Informed Consent to Treatment

For insurance patients including Kaiser CHP, Regence BCBS, MVA PIP auto accidents:

    Please print and complete only the top “patient” section, which ends with a signature and date. 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.

Alternatively, you may also upload any relevant docs to the online scheduler, under your “patient history” section. 

Populace Health Insurance Claim Form

For Worker’s Compensation patients:

I’m sorry. Populace Wellness is not accepting Worker’s Comp. claims at this time.

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