Puget Spine New Patient Appointment Request

Welcome to Puget Sound Spine and Sports Medicine!

Dr. Singh is accepting new patients on a limited basis.

The following must be submitted in order for your appointment request to be processed:

This form, completed in its entirety
A referral from your healthcare provider - We are not accepting self-referrals at this time
Your relevant medical records

Please note, if we do not receive all of the above items, your request may be automatically denied.

If you have seen Dr. Singh in the past and it has been less than two years, you do not need a referral. Medical records are still required.

Your relationship to the prospective patient?*

Your Name/Office Name

Patient Code of Conduct

Dear Prospective Patients,

I am committed to providing the best care to my patients. In recent years, access to treatment with me has become increasingly scarce as the demand for high quality care has grown. With this in mind, I have the following treatment guidelines:

My Role in Your Care

I serve primarily as a consultant in your care.
Please come prepared to clinic visits with your specific needs—such as requests for referrals or imaging—to maximize our ability to provide timely care.
I recommend that you maintain treatment with a primary care provider, as I do not provide ongoing prescription refills or routinely fill out paperwork (e.g., FMLA requests, return to work, etc.).

Between-Visit Communication

Our clinic strives to provide the best care while patients are in clinic and this is difficult if we are hampered by extensive between-visit patient requests.
Please limit these requests to urgent medical matters only, such as post-procedure concerns.
If you need to reach out to our staff for reasons other than urgent medical concerns, please be patient. Our staff typically responds to email and phone messages within three business days.
Note that I do not communicate via email with patients and communicate by phone only to address urgent medical matters. This is to maximize my clinic time.
We are committed to treating our patients with respect and we expect our patients to treat all of our practitioners and staff with respect in return.

These guidelines may mean that my practice is not a good fit for you. If that is the case, please discuss with your referring provider. My aim is to serve patients who benefit from the care I offer, and while in my care, we will continue to assess your needs and modify your treatment plan accordingly.

Sincerely,

Virtaj Singh, MD

Acknowledgement*

By checking this box, I acknowledge that I have read and understood the above Patient Code of Conduct and agree to adhere to its guidelines for the duration of my care with Dr. Singh.

Name*

First NameLast Name

Date of Birth*

Date

Gender

Phone Number*

Please enter a valid phone number.

Phone Type*

MobileHomeWorkOther

Email*

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

*Please note, we do not accept private/commercial health insurance plans.*

We accept the following insurance:

WA State Department of Labor and Industries (State Worker's Compensation)*
First-Party Personal Injury Protection claims (motor vehicle insurance)

If you do not have a Worker's Compensation or Personal Injury Protection claim, you will be considered "Self-Pay" and will need to pay out-of-pocket for your care. If you choose to submit your claims to your insurance company yourself, we can provide you with the necessary information to do so upon request.

*We do not take self-insured L&I/workers compensation claims (i.e. claims that go through Sedgewick, Corvel, OWCP, Eberle Vivian or other similar payers).

Insurance*

By proceeding, you are acknowledging that you understand we are not contracted with commercial health insurance and that you will be responsible for paying out-of-pocket for your care.

Insurance Company

Claim Number

Date of Injury

Date

Who can we contact about your claim?

This may be a claim manager, attorney, or general contact for your insurance. Please include contact's name, phone number, and email address if available.

Important note:

We accept only first-party Personal Injury Protection (PIP) claims (through your car insurance). We are not able to bill third-party claims (through the other party's car insurance) except in the case of pedestrians or bicyclists.

If you do not have PIP, or if your PIP exhausts, you will be considered self-pay. If you have concerns about the cost of continuing care on a self-pay basis, we will happily work with you on a payment plan or discuss other options as needed.

Please note, we do not hold balances in anticipation of case settlement.

In order to provide you with the highest quality care, we can only focus on one concern at a time. Please list the single most important issue you would like to focus on during your treatment in the Primary Concern field. If you have more than one concern, or any additional information you would like to share, please include that in the Secondary Concern field below.

Referring Care Provider*

Please include your providers name and credentials (i.e. PT, MD, DO, ARNP, ND, DC, etc.)

Primary Concern*

Please be specific. (Dr. Singh is not accepting new patients for medication-based pain management or non-focal EDS concerns.)

DO NOT CLICK ON "X" Please identify any areas of pain by shading this image. Mark an 'o' on any areas with numbness or tingling.

Have you been treated for this concern before? If so, by who?*

If you have never been treated for this issue before, write “No”.

Secondary Concern/Additional Information

Treatment Goals/Expectations*

Write N/A if you have no specific treatment goals or expectations.

Have you had imaging studies or other diagnostic tests? If so, please list below.*

If you haven’t, write “No”

Check below if your referring provider will be sending your referral and records separately.

My provider is sending my referral and/or records

If you have not already requested your records from your referring provider, you may do so by completing a Release of Information and sending it to their office. Click here to download a Release form from our website.

*We recommend this if you are not uploading records with this request.

If you are uploading your own referral and/or relevant past medical records, please do so below.

Puget Spine New Patient Appointment Request

Patient Information

Medical Information