Selkirk Neurology, PLLC
610 S Sherman Suite 201
Spokane WA 99202
Phone: 509-473-0885
Fax: 509-795-0895

Proud Regional Partner
Clinical Research
Provider Referrals New Patient Forms Insurance
Selkirk Neurology, PLLC is committed to providing quality and comprehensive healthcare while ensuring the procurement and protection of your personal information is convenient and compliant.
Patient forms are required for intake, continuity of care and insurance processing.
It may include a request for comprehensive health history data, an authorization to contact form and our financial policy outlining patient payment responsibility for all clinic services.
Referrals are required along with requested medical information to best determine how our clinic and Providers may serve your needs. We require the following NEW PATIENT REFERRAL/CONSULT document be completed by your Provider and sent along to request a consult or referral.
Call 509-473-0885 with any questions
Referral: Providers Only Please
Print & Complete
Fax 509-793-0883
Attn: Consult Referrals
New Patient Forms

Scheduled Patients
New Patient Paperwork is sent through the post if time allows as we schedule your appointment
Please complete all of these and bring to your visit
You may also access these documents HERE to PRINT and complete at your convenience. Please assist us in expediting your check-in process with your insurance card and ID ready
Questions? Contact Us
509-473-0885
info@selkirneurology.com
Medical Release of Information
PRINT the form below to request the
RELEASE OF YOUR MEDICAL RECORDS
This may be sent by post, brought to your visit or sent electronically to our FAX line.
ChartRequest is a HIPPA secure network that partners with Selkirk Neurology to secure your records electronically
Click ChartRequest logo ABOVE to request we send your Selkirk records to a care partner
or for your records as needed
Send Records to SELKIRK
Secure Online Submission
Click below to to be directed our HIPPA compliant 3rd party eSignature partner to request forms for direct submission online
Please Note: Emails for document signing will be from HelloSign and may post to a secondary use folder
i.e. Other or Spam
Call our Office if you need assistance
509-473-0885
Selkirk Neurology currently partners with the following plans.
We gladly work with patients to assist the authorizations process for some services but recommend you contact your Insurance Provider with any questions about your coverage
Premera Blue Cross & Blue Cross Blue Shield Plans
Kaiser Commercial
Medicare Advantage
Supplement Plans
United Healthcare
Commercial
Medicare Advantage
Supplement Plans
Cigna/GreatWest Healthcare
Aetna
First Choice Health Network
Medicare
Tricare-West
Ameriben Commercial
CHPW Medicare Advantage
GEHA
EBMS
HMA
Lifewise
Medicare Railroad Retirement
Premera Medicare Advantage
UMR
Pacific Source Commercial & Medicare Advantage
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