New Patient Intake Documents (Webform)

Intake forms to be completed prior to making an appointment

Please correct the errors described below.

Evergreen Integrative Medicine, LLP
New Patients of Dr. Trina Seligman

Please complete all sections of this new patient intake document prior to scheduling an appointment with Dr. Seligman.

Patient Information

Insurance Information

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    Patient Health History

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    Family Disease History:

    Lifestyle / Diet (specify type, amount, frequency)

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    Please indicate any CURRENT symptoms you are experiencing:

    Informed Consent Policy

    I hereby request and consent to the performance of naturopathic procedures (including examination, diagnostic testing, and the use of natural substances such as vitamins, minerals, botanical medicines, bioidentical hormones, and prescription drugs) on me (or on the patient named below, for whom I am legally responsible) by Dr. Seligman; a licensed Naturopath.

    I understand and am informed that, as in the practice of medicine and naturopathic medicine, there are some risks to the exam and treatment including, but not limited to Naturopathic Medicine- drug side effects, nutrient-drug interaction, and herb-drug interactions. I understand and am informed that results from treatments may vary and are not guaranteed. In addition, I understand that my compliance with diet recommendations, supplements, prescribed medications, prescribed exercises, and lifestyle modification will increase the effectiveness of my care and enhance or maintain the results. I understand a referral to another physician or specialist may be necessary due to the nature of my condition and limitations in the scope of practice of Naturopathic Medicine.

    I am aware that Naturopathic Physicians are considered primary care providers in the state of Washington. I acknowledge that the scope of practice of a Naturopathic physician has limitations including limited prescription privileges and lack of hospital privileges. Consequently, a referral to a specialist or emergency room may be deemed necessary under certain circumstances and in my best interest.

    I do not expect the doctor to be able to anticipate and explain all the risks and complications, and I wish to rely on the doctor to be able to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts known.

    I have read, or have had read to me the above consent. I have also had an opportunity to ask questions about its content, and by initialing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

    General Insurance & Financial Policy

    We HIGHLY recommend you careully review all of the information contained in this section.

    • Patients are responsible for payment of all charges incurred regardless of whether insurance pays or not.
    • As a patient of this office, it is your responsibility to know your benefits including whether or not your plan requires a co-payment for services. Our office does not verify insurance benefits for patient.
    • If your plan requires a co-pay, it is due at the time of service regardless of whether or not our staff asks for it. (If our biller can verify that services are not subject to a co-pay we will credit your account or issue you a refund).
    • If our office has to bill you for your co-pay, you will be charged a $5.00 administration fee.
    • Most supports, supplements and supplies cannot be billed to insurance and must be paid for at the time of service.
    • Overdue accounts past ninety (90) days may be assigned to a collection agency of our choice.  Interest of 1.0% per month may accrue on all past due accounts.
    • There is a $20.00 charge for any returned check.
    • Fee for no show or late cancellation with less than 24 hours notice: Yearly Physical or New Patient: $150 All others: $50
    • 24-hour notice is defined as 24 business hours prior to your appointment. (Weekends and holidays are not business hours.)
    • Our clinic is contracted with most insurance plans. It is your responsibility to verify in-network status before receiving services.
    • Our clinic does not accept Medicaid; including Apple Health. Medicaid and Apple Health patients are seen on a cash basis.

    Additional Information

    1. Patients are responsible for providing a correct address, phone number and a copy of their insurance card at each visit. You will receive a statement each month for any service billed to your insurance which has not been paid after 60 days from the date of service. Insurance is a contract between the patient and their carrier; your involvement would be expected on any unpaid claim(s) older than 60 days. We cannot accept responsibility for collecting on insurance claims or negotiating a disputed claim (such as patient eligibility or denial of benefits).
    2. Preventive Care (Annual Physical/Wellness) Exam Disclosure: Yearly physicals are defined by the American Medical Association as prevention focused, not problem focused. As a general rule of thumb, preventive care does not include any service or benefit intended to treat an illness, injury or medical condition. Preventive services are generally for health maintenance and screening; the detection of disease in the absence of symptoms. Therefore, if during the course of your visit additional concerns or conditions are discussed that require a diagnosis and/or other treatment, you may incur additional office and/or lab charges. These charges as well as the charges from your preventive care exam will be billed to your insurance company. If your insurance does not cover some or all of these additional charges you will be billed directly for the balance they indicate as "Patient Responsibility".
    3. Our provider can never know how your claim will be processed until the payment is received from your insurance company, therefore all services rendered will be billed using the appropriate code(s) per insurance requirements and national billing guidelines. We will not re-code (change a procedure or diagnosis code) and re-bill any service(s) unless a gross coding error has been made on our par.

    Supplemental Information

    1. Our providers render multiple types of services under the heading of naturopathic care (ND).
    2. As previously stated, our providers do not know how your claim will be processed until payment is received from your insurance company, therefore all services rendered will be billed using the appropriate code(s) per insurance requirements and national billing guidelines. If you have questions or concerns about how your treatment will be billed, they must be addressed either before or during your visit.

    Notice of Privacy Practices

    Evergreen Integrative Medicine complies with the Health Insurance Portability & Accountability Act (HIPPA). We protect confidential health care information, known as “Protected Health Information” (PHI). Below is a summary of patient privacy rights under HIPPA and our clinic's legal duties and privacy practices regarding your PHI.

    Uses & Disclosures of Your PHI

    • We may use or disclose your PHI for payment of your services. For example, we may send a report of your progress to your insurance company.
    • We may use or disclose your PHI for our normal healthcare operations. For example, one of our staff will enter your information into our computer.
    • We may share your PHI with our business associates, such as billing service. We have a written contract with each business associate that requires them to protect your privacy.
    • We may use your PHI to contact you. For example, we may send newsletters or other information.
    • We may also want to call and remind you about your appointments. If you are not at home, we may leave this information on your answering machine or with the person who answers the telephone. In case of an emergency, we may disclose your PHI to a family member or another person responsible for your car.
    • We may release some or all of your PHI when required by law.
    • If this practice is sold, your PHI will become the property of the new owner. Except as described above, this practice will not use or disclose your PHI without your prior written authorization.

    Patient Privacy Rights

    • You may request in writing that we not use or disclose your PHI as described above. We will let you know if we can fulfill your request.
    • You have the right to know of any uses or disclosures we make with your PHI beyond the above normal use.
    • As we will need to contact you from time to time, we will use whatever address or telephone number you prefer.
    • You have the right to transfer copies of your PHI to another practice. We will mail/fax your files for you.
    • You have the right to see and receive a copy of your PHI, with a few exceptions. Give us a written request regarding the PHI you want to see. If you also want a copy of your records, we may charge you a reasonable fee for the copies.
    • You have the right to request an amendment or change to your PHI. Provide us your request to make changes in writing. If you wish to include a statement in your file, please provide it to us in writing. We may or may not make the changes you request, but will include your statement in your file. If we agree to an amendment or change, we will not remove nor alter earlier documents but will add new information.
    • You have the right to receive a copy of this notice.

    If we change any of the details of this notice, we will notify you of the changes in writing. You may file a complaint with the Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, Washington, DC 20201. You will not be retaliated against for filing a complaint. However, before filing a complaint, or for more information or assistance regarding your health information privacy, please call our office at 425.999-4503. This notice goes into effect as of April 14th, 2003.

    Federal law requires that we obtain your written acknowledgment of receipt of the Notice of Privacy Practices. The patient hereby acknowledges that Evergreen Integrative Medicine has provided a copy of its Notice of Privacy Practices that describes how protected health information may be used and disclosed, and how to access this information. I understand that if I have questions or complaints I may contact Evergreen Integrative Medicine. I also understand that I am entitled to receive updates upon request if Evergreen Integrative Medicine amends or changes its Notice of Privacy Practices in a material way.

    Sign and Submit

    Your agreement to all policies is required to complete this document and receive an appointment. If you have questions or concerns with any policy or part of this document please contact our office by email at staff@eimed.com.


    My signature below is an indication that I have completed this document to the best of my abilities and have reviewed and agree with all policies presented.

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