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New Patient Appointment Request Form

New Patient Appointment Request Form

27Questions

HIPAA

Compliance

  • 1

    Thank you for your interest in Healing Roots Medicine!

    (Formerly Hearthside Medicine)

    We provide exceptional in-depth root-cause focused medicine, integrating functional and integrative medicine with conventional medicine when needed. We can prescribe and order labs and advanced imaging when needed as well as offer supplement/nutritional options for common health concerns.

    Once our staff gets you set up in our system, (1-2 business days) you will get an email from our Athena Health system saying you are registered and you may even self book your 1st apt from there.   

    Please note;
    We do not prescribe regular ongoing controlled substances such as Ambien, Lunesta, Sonata, Adderall, Ritalin, Xanax, Ativan, Percocet, Hydrocodone, Fentanyl.  We can refer you to a specialist if needed.  

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    (Formerly Hearthside Medicine)
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    We are sorry but we are currently at capacity for your insurance type and can not accept any new pateints at this time.

    We know this can be hard however, you are welcome to check back next month to see if we have opened up again.

    Medicaid/OHP/Medicare may not elect for cash option.

    Medicaide, OHP, & Medicare patients are barred from electing a cash rate due to our governent contract agreements.

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    If providence/MODA is billed for your visits you will be resoponsible for the entire balance as listed on your EOB which will be significanty higher then our cash rate. Cash/CC rate is due at time of service.
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    Medicaide, OHP. & Medicare patients are barred from electing a cash rate due to our governent contract agreements.
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    We are sorry your plan does not cover your visits at Healing Roots Medicine. 

    Next time your insurance is up for renewal consider opting for a package that does not require a medical home and we can try again at that time. 

    PacificSource is a local nonprofit insurance company that typically offers the best packages at the best prices for patients.

    We wish you the best of luck but are happy you did not end up with a surprise bill after being seen.

     

    Sincerely

    Healing Roots Medical Team

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    Hmmm,  We may not be in network with your insurance plan.  Please continue filling out your details and one of our representatives will reach out to you before your appointment to see if we are in network or not.

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    Great News!  We should be in network with yor plan. 

    Please select Next to continue signing up.

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    -
    Pick a Date
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    Please Select
    • Please Select
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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    Please Select
    • Please Select
    • Male
    • Female
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    Currently closed to new Medicaid/OHP/Medicare & Tricare West patients. We take Pacific Source commercial plans, First Choice, United, Regence, Blue Cross Blue Shield, MODA (Not 360 plans), HMA, Health Comp, & Providence.
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  • 24
    Please check appropriate box(es):
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    OHP/Medicaid/Medicare are not eligible for Functional Medicine
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  • 26

    Next Steps to Schedule your 1st Appointment

    1. Our staff will get you set up in our system by 1-2 business days and then you should get an email from our Athena Health system inviting you to register for the patient portal.
    2. You can then convienently self schedule a new patient visit from the patient portal or "Athena Patient" app.
    3. If you do not hear from us please feel free to call us.

    You can usually get scheduled within 1-2 weeks!

    New patient consents & health history questionnaires are done virtually via Txt ahead of your appointment.

    You will recieve a text message 4 days and 1 day before your appointment.

    We require these be done ahead of time please.

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  • 27
    Formerly Hearthside Medicine
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