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

Kelvin Franke, DO (Lynnwood):
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.
Preferred Location or Provider*

SeattleLynnwoodEitherNot Specified
Seattle Clinic Providers*

Any Seattle ProviderRichard Seroussi, MDLaura Lewis, ARNP
Lynnwood Clinic Providers*

Kelvin Franke, DO

Patient Demographics
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

Insurance Information
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 Information
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.
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!