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.

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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.

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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.

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Call 509-473-0885 with any questions

Referral Providers Only Please
Print & Complete
 Fax 509-793-0883
 Attn: Consult Referrals

New Patient Forms

Health
History

Financial
Agreement

Notice of 
Privacy

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 

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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

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Questions? Contact Us
509-473-0885
info@selkirneurology.com

Medical Release of Information

PRINT the form(s) below to request the

RELEASE OF MEDICAL RECORDS

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These may be sent by post or 

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Choose SEND TO to request records be sent to Selkirk Neurology so we may serve you better

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Choose FROM to request we send your Selkirk records to care partners

NEW!
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

Regional Care Providers

Insurance Information

Selkirk Neurology currently partners with the following plans

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Call our office with any questions

Premera Blue Cross and 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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Providence Neurology

105 W. 8th Avenue, Suite 318C

Spokane, WA 99204

509-474-6650

Valley Neurology

11917 E. Broadway Avenue

Suite 201

Spokane Valley, WA 99206

509-676-3876

MultiCare Deaconess Hospital Neuroscience Institute

910 W. 5th Avenue, Suite 1000

Spokane, WA 99204

509-342-3200

Kootenai Clinic Neurology

700 West Ironwood Drive, #158

Coeur d'Alene, ID 83814 208-625-5100

Neurology Clinic at UW Medical Center

1959 NE Pacific Street

Seattle, WA 98195 206-598-7688

Swedish Neurology – Cherry Hill

550 17th Avenue, Suite 400

Seattle, WA 98122

206-320-3494