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

New Patient Forms

Doctor with Computer

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

Medical Release of Information

PRINT the form below to request the


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


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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


         Medicare Advantage

         Supplement Plans

Cigna/GreatWest Healthcare


First Choice Health Network



Ameriben Commercial 

CHPW Medicare Advantage





Medicare Railroad Retirement

Premera Medicare Advantage


Pacific Source Commercial & Medicare Advantage

Providence Neurology

105 W. 8th Avenue, Suite 318C

Spokane, WA 99204



Valley Neurology

11917 E. Broadway Avenue

Suite 201

Spokane Valley, WA 99206



MultiCare Deaconess Hospital Neuroscience Institute

910 W. 5th Avenue, Suite 1000

Spokane, WA 99204



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