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Patient Forms

New and existing patient forms needed for care

Download and print your patient intake forms

Please return your forms to us by fax at (360) 647-1542 or by mail to 2216 Cornwall Ave., Bellingham, WA 98225.

If you don't see a form you're looking for, please call us at 360-647-1900

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


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

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