Forms

PDF Forms (all PDF Downloads)

Packets

Member Registration Packet  (for adults and single dependents, one packet per person)

Dependent Registration Packet (for two or more dependents under the age of 17, up to five dependents per packet)

Individual Forms

Member Registration Form

Patient Agreement

 Billing Information & Authorization

Authorization to Email Protected Health Information

Acknowledgement of Privacy Practices

Medicare Statement of Understanding

Service Cancellation Form (currently not working – contact us for cancellation)

Online Information

List of Patient Services

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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