PATIENT ENROLLMENT

patient enrollment steps

STEP 1: CONTACT

Contact our Admissions Manager, Josie Lenz, at (920) 372-4168 or via email at admissions@sequoiaintegrativemedicalservices.com.

STEP 2: COMPLETE FORMS

Our Admission Packet consists of the following forms:

New Patient Admission Checklist
Notice of Privacy Practices (NPP)
Patient Admission Information
Release of Information Form
Consent for Medical Care and Treatment
New Patient Admission Questionnaire
Chronic Care Management Enrollment Form
Telehealth Urgent Care Services Form
Remote Patient Monitoring Consent Form

STEP 3: SUBMIT FORMS

Submit completed admission packet via email or fax.

Email: admissions@sequoiaintegrativemedicalservices.com

Central Fax: (920) 543-5288

Western WI Fax: (715) 520-5288

Upon submission of forms you/your loved one will be placed on the provider’s schedule for a visit within the next calendar month. Once paperwork has been processed by our billing department (typically 1-2 business days) we are able to address and concerns/needs.

PATIENT ENROLLMENT

patient enrollment steps

STEP 1: CONTACT

STEP 2: COMPLETE FORMS

STEP 3: SUBMIT FORMS

Do you have questions?

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