New Patient Request An Appointment

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New Patient Appointment Request

Please read all the fine print when completing your new patient online request.

Welcome to Seattle Spine and Sports Medicine!

Seattle Spine and Sports Medicine has moved to a model of care focused on patients primarily dealing with post-collision injuries and worker's compensation claims.

If you are seeking a visit with Dr. Virtaj Singh, please contact his new clinic: https://soundspineandsport.com/

If you are seeking a visit with Dr. Matthew Grierson or Dr. Nancy Kadel, please contact them at their new clinic: https://soundspineandjoint.com/index.html

Today's Date

Printed Name

First Name

Last Name

Signature

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Use your mouse or finger to draw your signature above

Preferred Location or Provider

Please click on your preferred location and provider below to learn more about which provider will be the best fit for you. If you are unsure, select any provider and we can make a recommendation to you during scheduling.

Preferred Location or Provider*

Seattle Lynnwood Either Not Specified

Please select preferred location and provider.

Seattle Clinic*

Any Seattle Provider Richard Seroussi, MD

Choose your provider. More than one can be requested.

Lynnwood Clinic*

Kelvin Franke, DO

Choose your provider.

Appointment Request for Richard Seroussi, MD

Richard Seroussi, MD - Bio

Click here to read more about Dr. Seroussi's medical practices and interests.

Accepted Insurances

PIP (Personal Injury Protection)
LOG/LIEN - Attorney Required
Self Pay
Washington State Workman's Comp (L&I) - Case by case basis
**Effective 3/1/23 our clinic no longer accepts Self-Insured Workman's Comp (3rd party administrators) Claims**

Referring Care Provider

Please include your provider's credentials above. IE: PT, DC, ARNP, MD, DO, PA-C, Etc.

Appointment Request for Kelvin Franke, DO

Kelvin Franke, DO - Bio

Click here to read more about Dr. Franke's medical practices and interests.

Accepted Insurances

PIP (Personal Injury Protection)
LOG/LIEN - Limited Availability - Attorney Required
Washington State Workman's Comp (L&I)
**Effective 3/1/23 our clinic no longer accepts Self-Insured Workman's Comp (3rd party administrators)**

For the time being, the Lynnwood location is exclusively focused on post-collision injuries and worker's compensation claims.

Patient Demographics

Who is filling out this form?*

Myself Someone Else Referring Office Attorney SSASM

Relationship to Patient*

Please list your relationship to the patient if you are filling out this form for them.

Referring Office or Attorney's Office Name*

Please include your office name if filling out this form for the patient.

Referring Office or Attorney's Office Phone Number*

Phone number format: 555-555-5555 (Ext. if applicable)

Extension

Please list extension if applicable.

Patient Name*

First Name

Last Name

Date of Birth*

Gender

Cell Phone*

Phone number format: 555-555-5555

Is an Interpreter Needed?*

Yes No Unknown

HEALTH INSURANCE, SELF-PAY, OR MVA INSURANCE PATIENTS

If you require assistance with scheduling please provide a phone number for an English speaking friend/family member/personal interpreter to help with scheduling.
We cannot provide an interpreter for your appointment - You are responsible for bringing someone to the appointment that can help translate.

STATE L&I PATIENTS

Interpreters are available upon request for all State L&I patients (All languages)
We can use an interpreter to help schedule and an interpreter will be provided for your appointment. This is only provided for State L&I patients.
You cannot request a specific interpreter for your appointment. We have to follow L&I guidelines and request an interpreter through interpreting works.

Language*

Please list the language the patient speaks.

Email Address*

You will be contacted by email if we are missing any information needed to process your request.

Insurance Information

Accepted Insurance*

We do not accept: Medicare, United Healthcare, Community Health Plans, Molina/DSHS/Medicaid, Apple Health, Cigna, 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).

OON Insurance Name

Understanding Motor Vehicle Accident (MVA) Claims

PERSONAL INJURY PROTECTION (PIP)

We will bill your own car insurance under your PIP policy¹unless these benefits are exhausted or not available.
If PIP is not available, we will bill your private (commercial) health insurance if available and if we are contracted with this insurance carrier. We depend on you to provide your commercial insurance info prior to scheduling your first appointment.

LETTER OF GUARANTEE/LIEN (LOG/LIEN)

If PIP is not available and you do not have - or we do not contract with - your commercial insurance, we are open to treating you on a Letter of Guarantee (LOG) provided:

1. You want and would benefit from treatment from our clinic.

2. You have good legal representation - specifically a reputable attorney.

The LOG states that you and/or your attorney will pay us at the time of your MVA claim settlement with available funds.
At Your First Visit:
We ask that you sign a LOG, given uncertainty about PIP benefits and other payment sources.
Note that the LOG may never be needed, but it both protects us and allows you to get the care you need in a timely manner.
We will forward the LOG to your attorney for their signature as well.

ACCEPTED COMMERCIAL INSURANCES

Premera²
Lifewise²
Regence PPO
First Choice PPO
Kaiser (Access PPO only)

Note: Richard Seroussi, MD and Laura Lewis, ARNP are not contracted with health insurance.

¹First party PIP (Personal Injury Protection) refers to the claim you have opened with your car insurance company. It is no-fault insurance and allows you to get timely treatment independent of liability for your MVA.

²Not all Premera and Lifewise plans are accepted by us, please check coverage with our staff.

Accepted MVA Insurances*

We do not accept: Medicare, United Healthcare, Community Health Plans, Molina/DSHS/Medicaid, Apple Health, Cigna, and Aetna (Eff. 10/01/2021)

Letter of Guarantee (LOG/LIEN) Appointment Request

If PIP is not available and you do not have - or we do not contract with - your commercial insurance, we are open to treating you on a Letter of Guarantee (LOG) provided:

1. You want and would benefit from treatment from our clinic.

2. You have good legal representation - specifically a reputable attorney.

The LOG states that you and/or your attorney will pay us at the time of your MVA claim settlement with available funds.
At Your First Visit:
We ask that you sign a LOG, given uncertainty about PIP benefits and other payment sources.
Note that the LOG may never be needed, but it both protects us and allows you to get the care you need in a timely manner.
We will forward the LOG to your attorney for their signature as well.

I have read and understand my Attorney and I have to review and sign Seattle Spine and Sport's Medicine Letter of Guarantee (LOG) before I can schedule an appointment on a lien basis.

Yes No

MVA BILLING INFO

Did your accident occur in WA state?*

Yes No I'm not sure

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 (please refer to MVA billing instructions above for help).

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

Extension

Please list extension if applicable.

Date of Injury*

Attorney's Office Name (If applicable)

If you are currently working with an attorney and would like them on file please list their office name.

Attorney's Office Phone Number (If applicable)

Phone number format: 410-382-8070

Extension (If applicable)

Please list extension if applicable.

Health Insurance Name (If applicable)*

Please provide health insurance name. We use health insurance as a secondary billing option to PIP coverage if necessary. If you do not have health insurance coverage please write N/A.

Member ID Number (If applicable)*

Please provide your member ID #, prefix included. If you do not have health insurance coverage please write N/A.

Group Number (If applicable)*

Please provide your group #. If you do not have health insurance coverage please write N/A

Subscriber & Network

Please write subscriber and network once verified w/ Availity or OHP

LIEN BILLING INFO

Attorney's Office Name*

To request an appointment on a lien, your attorney's contact information is required.

Attorney's Office Phone Number*

Phone number format: 410-382-8070

Attorney/Paralegal Email

If you have it, please provide your attorney or paralegal's email.

L&I BILLING INFO

L&I Claim Appointment Request

We only accept Washington State Worker's Compensation Claims (State L&I).

We do not acceptOWCP Federal Worker's Compensation Claims or Crime Victim Claims.

**Effective 3/1/23 our clinic no longer accepts Self-Insured Workman's Comp (3rd party administrators)**

Has a referral been faxed to our office?*

Yes No I'm not sure

A referral must be faxed to our office from the referring provider before scheduling.

We will contact you by email if your referral is not received by the time your online request is processed.

Seattle/Lynnwood Fax Number: 206-324-1178

L&I Claim Number*

Please provide claim number for L&I claim.

Date of Injury*

HEALTH INS/OTHER BILLING INFO

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*

Please provide your group #. If you do not have health insurance coverage please write N/A

Subscriber & Network

Please write subscriber and network once verified w/ Availity or OHP

Insurance Card

No File Chosen

File uploads may not work on some mobile devices.

Please upload the front of your insurance card if applicable. This will help us confirm if we are in network with your plan.

Other Insurance*

Please list insurance name and member ID number. We will verify if we are in network during the time of scheduling.

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.

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 with us. We can also address any other 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.

Duration of Concern*

How long has this concern been bothering you? Your answer doesn't need to be exact, just a general idea.

Clinic Response

Document here how we reached the patient.

MISSING INFORMATION

STATUS

SSASM staff: Use this to write any additional notes for patients.

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

Requests are processed in the order they are received. Please allow 24 business hours for processing. Appointments are typically available with in 1-3 weeks.

We are working as fast as we can to process our faxed and online requests in the order they are received. We will give you a call for scheduling options as soon as possible.

For urgent concerns or questions, please contact:

care@seattlespine.com