Patient Forms

New Patient Forms Adult

Patient Intake Form
Download & Print

New Patient Forms Pediatric
(Under 18)

Pediatric Intake Form
Download & Print

Miscellaneous
Forms

Patient Financial Policy

Patient Credit Card Policy

PHQ-9 Depression Questionnaire & GAD-7 Form

Release of Records

Insurance Providers

Due to the financial burdens placed on small businesses and ever increasing operation expenses, effective November 1, 2022, we will no longer accept new Medicaid insurance including Apple Health, Molina, CHPW, Coordinated Healthcare, Amerigroup and DSHS as primary insurance.  This change also applies to existing patients who transition to Medicaid insurance as their primary insurance.  These patients will need to find medical care outside of Mt. Shuksan Family Medicine and Dermatology.

Mt. Shuksan Family Medicine and Dermatology accepts most major medical insurance carriers. Participation means the practice will file claims to these insurance companies and will make the proper fee discounts according to our contract with that company. We will verify insurability before you are seen. Payment of any co-pay will be expected at the time of visit.

We reserve the right to change or adjust information on this page as insurance carriers and status can change. Patients should confirm coverage with their insurance carrier.

• Premera
• LifeWise
• Regence
• United Health Care (UHC)
• United Medical Resources (UMR)
• First Choice Health Network
• Aetna
• Cigna
• Kaiser (PPO, HMO, Core)
• TriCare
• Labor & Industries (Worker’s Comp)
• MVA Insurance
• Regence Group Administrators
• Health Management Administrators