New Patient Appointment Request

New Patient Appointment Request

Please read all of the FINE PRINT when completing your new patient online request.
We offer specialized care for patients primarily dealing with motor vehicle accident injuries and work-related injuries.

Accepted Insurance Information

Richard Seroussi, MD, Kenneth Leong, MD, and Laura Lewis, ARNP (Seattle):
PIP (Personal Injury Protection)
Third Party Auto (Lien)
Washington State Department of Labor & Industries (Worker's Compensation) -- On a case-by-case basis

Tiffany Mathias, MD (Lynnwood):

PIP (Personal Injury Protection)
Third Party Auto (Lien)
Washington State Department of Labor & Industries (Worker's Compensation)

Kelvin Franke, DO (Lynnwood):*

We're pleased to share an important update: Effective April 1, 2026, Dr. Kelvin Franke will be transitioning to his new independent practice, Sound Injury & Electrodiagnostics.

To schedule with Dr. Franke: 425-678-2044 | soundinjury.com

PIP (Personal Injury Protection)
Third Party Auto (Lien)
Washington State Department of Labor & Industries (Worker's Compensation)
First Choice Health Network*
Regence*

*Not accepting all plans, this will be verified at the time of scheduling.
Preferred Location or Provider

Please click on your preferred location and provider below. If you are unsure, select not specified and we can make a recommendation to you during scheduling.

Note: Brain Injury Medicine of Seattle (BIMS) services are only available at our Seattle location.
Preferred Location or Provider*

Seattle - Seattle Spine & Sports Medicine & Brain Injury Medicine of SeattleLynnwood - Seattle Spine & Sports MedicineEitherNot Specified
Seattle Clinic Providers*

Any Seattle ProviderRichard Seroussi, MDLaura Lewis, ARNPKenneth Leong, MD
Lynnwood Clinic Providers*

Kelvin Franke, DOTiffany Mathias, MDNot Specified
- Who is filling out this form?*
  
  MyselfSomeone ElseReferring OfficeAttorneySSASM
- Relationship to Patient*
- Referring Office or Attorney's Office Name*
- Referring Office or Attorney's Phone Number*
  Please enter a valid phone number.
- Extension (if applicable)
- Clinic Only- Write your initials please!
- Patient Name*
  
  First NameLast Name
- Date of Birth*
  
  MonthDayYear
  Date
- Gender
- Cell Phone*
  Please enter a valid phone number.
- Is an Interpreter Needed?*
  
  YesNoUnknown
- Language please specify*
- Email Address*
  You will be contacted by email if we are missing any information needed to process your request.
- Address
  
  Address Line 1
  
  Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Accepted Insurance*
  We do not accept: Medicare, United Healthcare, Community Health Plans, Molina/DSHS/Medicaid, Apple Health, Cigna, Premera and Aetna (Eff. 10/01/2021). We do not accept: Self-insured worker's compensation claims [City of Seattle, CorVel, Eberle Vivian, Gallagher Bassett, Penser, Sedgwick, Etc.] (Eff. 03/01/2023).
- Date of Injury*
  
  MonthDayYear
  Date
- Did your accident occur in WA state?*
  
  YesNo
- Motor Vehicle Insurance Name (Your Insurance)*
  Please provide your motor vehicle insurance name for selected insurance. PLEASE NOTE: This is not for the other party's insurance.
- MVA Claim Number*
  Please provide your claim number for your motor vehicle accident.
- Claim Adjuster's Name*
  If you know the name of the claim adjuster assigned to your MVA claim please list it here. If you do not know write N/A. PLEASE NOTE: All Geico claims must provide claim adjuster's information.
- Claim Adjuster's Phone Number*
  Please include your claim adjuster's phone number, we might be unable to verify PIP coverage if this is not provided. Phone number format: 555-555-5555
- Attorney's Office Name*
  If not applicable please write N/A
- Attorney's Office Phone Number*
- Paralegal Name
- Paralegal Name Email
- Has a referral been faxed to our of office*
  
  YesNoI'm not sure
- L&I Claim Number*
  Please provide claim number for L&I claim.
- Claims Manager Name*
- Claims Manager Phone Number*
- Member ID Number*
  Please provide member ID number, prefix included. Specific plan network will be verified with patient during the time of scheduling.
- Group Number*
- Self-Pay Appointment Request
  
  Our self-pay consult is between $300-$600, depending on the complexity of the exam, which is determined by the provider at the time of service. Subsequent office visits are $200-$400 and any treatments are an additional cost to the office visit. We offer a 20% discount for paying at the time of service.
- OON Insurance
- Other-Please Specify
- Referring Care Provider/ Self-Referred*
  If referred by a provider please include their credentials. IE: PT, DC, ARNP, MD, DO, PA-C, Etc.
- At Seattle Spine and Sports Medicine we strive to provide the best patient care possible. Focusing on one area of concern at a time is the most efficient way we can care for you. Please provide your primary and secondary concern(s) below.
- Primary Concern*
  Remember: Please list your primary focus for your visit. We can also address any secondary concern(s) in a separate appointment. Your secondary concern(s) can be listed below.
- Secondary Concern/ Additional Information*
  Please list any secondary concern(s) you would like us to address in another appointment. If you have any additional information you would like to include please write it here. If you do not have any additional concerns/information please write N/A.
- Have you had any imaging or diagnostic testing?*
  
  YesNo
- Please Explain*
  Example: X-Rays, MRI, EMG/NCS, Etc. Please include where you have received your imaging/testing if known.
- OPTIONAL: Please upload any relevant documentation here:
  
  Cancelof
- Thank you for taking the time to fill out our new patient online request!
  
  Please allow up to 1 week for processing.
  
  If you do not recieve a call after 1 week please let our referral coordinator know by emailing care@seattlespine.com
  
  We are not a primary care office or walk in clinic. If you have an urgent concern it may be best to go to an urgent care or primary care physician while you wait for an appointment. Our typical wait time for an appointment is 3-6 weeks.
- Should be Empty:

New Patient Appointment Request

Self-Pay Appointment Request

Thank you for taking the time to fill out our new patient online request!