- Insurance Information -

Upload Insurance Card - PNW Wound Specialist, LLC
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Social Security number (optional)
Optional: used for patient identification and insurance eligibility lookup when a payer supports it, including Medicare MBI lookup. You may leave this blank and provide your current member ID or contact us. Declining does not prevent care. Do not enter someone else’s SSN.
Insurance Status (choose one)
Self-Pay Acknowledgment
If you have insurance, enter the plan and member number and send a clear image of both sides of the card. You may take a photo OR upload a saved image; you do not need to do both. If you cannot provide a card or are unsure about coverage, call 509-209-9033 for help.

If you are uninsured or want to discuss paying yourself, let us know. We will review pricing, available coverage, and any required estimate before care. This form does not waive Medicare, Apple Health, or other payer protections or make you responsible for every denied claim.

Please use this form or contact us to arrange a secure method. Do not email your Social Security number or insurance card through ordinary email.
Name of Primary Insurance
Primary insurance member ID / policy number
Use the number shown on your current card. For Medicare, enter your Medicare Beneficiary Identifier (MBI), not an SSN.
Primary card front — take a photo (or upload below)
Primary card back — take a photo (or upload below)
Primary card front — upload an image (or take a photo above)

Cancelof
Primary card back — upload an image (or take a photo above)

Cancelof
Secondary Insurance
Name of Secondary Insurance
Secondary insurance member ID / policy number
Patient full name and date of birth
Enter the patient’s legal name and DOB (MM/DD/YYYY) so we can match insurance information to the correct record.
Secondary card front — take a photo (or upload below)
Secondary card back — take a photo (or upload below)
Secondary card front — upload an image (or take a photo above)

Cancelof
Secondary card back — upload an image (or take a photo above)

Cancelof
Consent Check Box
Patient or Authorized Representative Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Upload Insurance Card - PNW Wound Specialist, LLC