New Medicare Patient

Additional Form

Call Us:  360.293.4343

Prospective Patient Packet

Clinic Documents

Instructions
1. STOP - before filling out an application, please confirm the following:

  • We accept your insurance (please call us to confirm)
  • We're accepting new patients. Please call one of our offices to see which providers are available to take in new patients

2. Print off all pages of the Patient Registration Packet (or stop by one of our locations and request the packet)
3. If you are a Medicare patient, print the Secondary Payer form located underneath the packet box
4. Print and read through the Clinic Documents available on the right. The "Privacy Policy" is also available to read on the "Privacy Policy" drop down
5. Fill out each new patient form in it's entirety
6. Return ALL forms to a receptionist for processing
    **Incomplete packets will be returned - please return ALL pages**

Processing Your Application
Once we receive your completed application packet, we will reach out to your previous primary care provider to request your records. Once we receive records, we will give your packet to the provider you would like to see and they will review to see if they can meet your needs. 

Often, your application may take weeks to process because we are waiting for your previous provider to send records. We continue to send requests but we can only receive records at the pace they are willing to send them. We recommend that you call them as well and request attention to your records if you would like to speed up the process.
 
Your First Visit
Please bring the following in so we can scan them to your patient account:
1. Driver's License or Photo ID
2. Primary Insurance Card
3. Secondary Insurance Card (if applicable)
4. Prescription Drug Card (if different from your insurance)

 Subsequent Visits
To comply with regulations, we must confirm the following at each visit:
1. Phone Number
2. Mailing Address
3. Primary Insurance
4. Secondary Insurance
5. Emergency Contact

You will also be asked to bring your medication bottles in with you for each visit, it's important for us to have the correct medications and dosages in your chart. There are many reasons that we request that you bring these medications in for each visit; often, patients are prescribed medications elsewhere and we are not notified; often, patients do not realize they've bought a different dosage of over-the-counter medications; often, patients do not realize their supplements influence their lab results and health and we are not made aware so that we can take those into consideration. 

​By bringing your medications in, you are taking charge of your own health and helping us ensure quality and safe care.

Please click on the "Resources" button to read about our 72 hour medication refill policy, co-payments, billing, urgent calls, appointments, test results, etc.

Island Internal Medicine

La Conner Medical Center

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