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Assurance Healthcare & Counseling Center

Membership Family Medicine in Yakima, WA

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Forms

PDF Forms (all PDF Downloads)

Packets

Member Registration Packet  (for adults and dependents ages 13 and up – one per person)

Dependent Registration Sheet (simple sheet for any dependents age 12 and younger – up to 5 per sheet)

Individual Forms for Reference Only! The above packet assumes agreement with all forms below.

Patient Agreement

Billing Information & Authorization

Authorization to Email Protected Health Information

Acknowledgement of Privacy Practices

Medicare Statement of Understanding (only for those eligible for Medicare, typically those 65 and older)

Online Information

List of Patient Services

Service Cancellation Form

If you can’t find what you’re looking for, you can always contact us here, or call our office at 509-823-4650.

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Free Download

Our Guide to Pairing Insurance with Assurance Membership

60 Second Membership Overview…

https://youtu.be/GRq2EiAyjIg

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Information

Assurance Healthcare & Counseling Center

3611 River Road, Suite 200
Yakima, WA 98902

(509) 823-4650
Fax: (509) 823-4652

Monday: 8am – 5pm
Tuesday: 8am – 5pm
Wednesday: 8am – 5pm
Thursday: 8am – 5pm
Friday: 8am – 5pm

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