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 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

Kenneth Leong, MD (Seattle):

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

Daniel Lee, DO (Seattle)

PIP (Personal Injury Protection)
Third Party Auto (Lien)

Tiffany Mathias, MD (Lynnwood):

PIP (Personal Injury Protection)
Third Party Auto (Lien)
Washington State Department of Labor & Industries (Worker's Compensation)
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 Clinic Providers
Lynnwood Clinic Providers
- Who is filling out this form?
- Relationship to Patient
- Referring Office or Attorney's Office Name
- Referring Office or Attorney's Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Extension (if applicable)
- Clinic Only- Write your initials please!
- Patient Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Gender
- Cell Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Is an Interpreter Needed?
- 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
  Please note our office does not accept commercial health insurance
- Did your injury occur while you were working or performing job-related duties?
- Date of Injury
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Did your accident occur in WA state?
- 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
- 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
  
  Please note that our clinic does not accept health insurance.
  
  Our self-pay consult is between $600-$750, depending on the complexity of the exam, which is determined by the provider at the time of service. Subsequent office visits are $300-$540 and any treatments are an additional cost to the office visit. We offer a 33% discount for paying at the time of service.
- OON Insurance
- 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?
- 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!