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
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
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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