New Patients and Provider Referrals         

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.

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Provider Referrals are required with requested information to best determine how our clinic and our providers can serve your needs. We require the following NEW PATIENT REFERRAL document be completed and sent along with all requests for consult or referrals.

New Patient Referral/Consult Form

Please: Print, Complete, Fax

New Patient Paperwork

You will receive new patient paperwork through the post if time allows as we schedule your appointment.  

Please complete these and bring to your visit. 

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You may also access these documents to print at your convenience or for online submission to assist us in expediting your check-in process.

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Questions? Call Us at 509-473-0885

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Paper Submission

Click the below links to access the form(s) you may print 

Medical Records may be released to Selkirk clinic with a Provider to Provider request. Call office with questions.

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1. Patients may REQUEST records be sent 

PATIENT RECORDS to SELKIRK

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2. Patients may  REQUEST their SELKIRK records be shared PATIENT RECORDS from SELKIRK

Online Submission

Click the below links to to be directed by HelloSign, a  HIPPA compliant 3rd party eSignature partner, to access forms for direct submission

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