New Patient Intake Form

Personal Information
*Red fields are required.


Insurance Information

Health Concerns in order of importance

Current Physicians

Health History

Authorization to Release Medical Records

I give permission to have medical information sent to:

            Red Cedar Wellness Center
            10601 116th Ave NE, Ste. 100 Bellevue, WA 98004-3034
            Phone Number: (425)-451-0999    Fax Number: (425)-451-7399

I understand that my records may contain information regarding the diagnosis or treatment of HIV/AIDS, sexually transmitted diseases, drug and/or alcohol abuse, mental illness, or psychiatric treatment. I give my specific authorization for these records to be released.

I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment or enrollment). However, I do have to have this authorization for:

  • To take part in a research study, or
  • To receive health care when the purpose is to create health information for a third party

I may revoke this authorization in writing. To view the process for revoking this authorization, please read the Privacy Notice to our patients. I understand that once I disclose health information, the person or organization that receives it may re-disclose it, at which time it may no longer be protected under Privacy laws.


*EXCLUDE the following information from the records released

Drug/Alcohol abuse/treatment & diagnosisSexually Transmitted DiseaseHIV/AIDS diagnosis/treatment/testingMental Illness or Psychiatric diagnosis/treatment

Provider Fees and Policies

Regular Office Hours: The business office is open Monday through Friday 10:00am to 5:00pm, with closure from 1:00pm to 2:00pm for lunch. Doctors are available by appointment. Massage therapy and counseling services are available at varying times including weekends by appointment only.

Insurance Billing: Drs. James, Martin, and Reddeman are credentialed by most major insurances. It is the patient’s responsibility to check if our doctors are covered by your specific insurance plan. If Dr. Martin is not listed or covered for Naturopathic services, insurance billing may be possible under her additional Nurse Practitioner status. Claims denied by your insurance plan will be billed to you directly.

Visit Consultations and Fees: The first office consult, which includes a comprehensive intake, review of medical records, physical exam, and initial treatment plan, generally lasts 60 minutes and ranges from $200-$350. Follow-up visits last 30 minutes and range from $100-$200. Acupuncture services and biofeedback training are provided in conjunction with a physician follow-up visit. Labwork and nutritional supplements are not included in these fees. Massage and counseling services have varying fees. Payment is due on day of service. We accept cash, checks and Mastercard or Visa. There is a $25.00 fee for all returned checks.

Telephone Consultation: After an initial visit, telephone or Skype consultation appointments are available for those who live more than 100 miles away. Insurance will not cover this service. Fees for a telephone consult are $75.00 for each 15 minutes. Brief (5 minutes or less) phone calls are accepted at no charge. Messages are checked daily and will be returned within 48 hrs.

Email Policy: Email is not a substitute for an office visit. If you need clarification of supplement dosage, medication instruction or refill, this will be provided by email. Changes in symptoms or changes to the treatment protocol must be addressed in person.

Medical Records and Confidentiality: Your medical records are confidential and require your written authorization before they can be released to other health care providers or other approved recipients.

Appointment Cancellations: We understand that circumstances occasionally arise that will change your plans. You may cancel at no charge if you call at least 24 hours before your appointment. If you do not cancel or fail to come for your appointment, a fee of $50.00 will be charged.


HIPAA Consent for Use and Release of Information

I give permission to Red Cedar Wellness Center to release any information about me, my health, the health services provided to me, or payment for my health services which may be necessary:

For my treatment - to any physician, or other health care providers or facilities which need the information for my continued care, or

For payment purposes - to determine whether I am eligible for insurance coverage and if this treatment is authorized for payment by my insurance. This information may also be used to process an insurance claim, and for billing and collection purposes, or

For my treatment to persons associated with me named below.

By signing this form, I authorize Red Cedar Wellness Center and associated providers to communicate via E-Mail, telephone, and in person with me and with other health care providers and associated persons as necessary for my medical care and treatment.

My signature on this authorization indicates that I am giving permission for the uses and disclosures of my protected health information. I hereby release Red Cedar Wellness Center (RCWC), its associated providers, and its employees from any and all liability that may arise from the release of information as I have directed.

My signature confirms that I am informed of my rights to privacy regarding my protected health information under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that I may request in writing that RCWC restricts how my private information is used or disclosed to carry out treatment, payment, or other healthcare operations. I understand that RCWC is not required to agree to my requested restrictions, but if agreeable is then bound to abide by such restrictions.

Informed Consent for Treatment

I hereby authorize the physicians at Red Cedar Wellness Center to perform or refer for the following specific procedures as necessary to facilitate my diagnosis and treatment:

Common diagnostic procedures: e.g., venipuncture, Pap smears, radiography, laboratory, X-ray.
Minor office procedures: e.g., dressing a wound, ear cleansing.
Medicinal use of nutrition: e.g., therapeutic nutrition, nutritional supplementation, IV nutrients, and intramuscular vitamin injections.
Botanical medicine: botanical substances may be prescribed as teas, alcoholic tinctures, capsules, tablets, creams, plasters, or suppositories.
Homeopathic medicine: the use of highly dilute quantities of naturally occurring plants, animals, and minerals to gently stimulate the body’s healing responses.
Physical Medicine: e.g., use of massage, muscle stretching, exercise therapy, naturopathic manipulation to relieve pain and improve function. May also include use of heating pads, micro-current electrical therapy, craniosacral therapy, or cryotherapy.
Hydrotherapy: e.g., constitutional hydrotherapy treatments with electrostimulation, contrast baths, and hydrocollator packs.
Pharmaceutical medicine: e.g., prescription of drugs or over-the-counter medication.
Lifestyle counseling and hygiene: e.g., diet therapy, promotion of wellness including recommendations for exercise, sleep, stress reduction, and balancing of work and social activities.
Psychological counseling

I recognize the potential risks and benefits of these procedures as described below:

Potential risks: allergic reactions to prescribed herbs and supplements, side effects of natural medications, inconvenience of lifestyle changes, injury from injections, venipuncture or procedures.

Potential benefits: restoration of health and the body’s maximal functional capacity, relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its progression.

Notice to pregnant women: All female patients must alert the doctor if they know or suspect that they are pregnant as some of the therapies used could present a risk to the pregnancy.

With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by Red Cedar Wellness Center or any of its personnel regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time.

I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself or my representative or unless it is required by law. I understand that I may look at my medical record at any time and can request a copy of it by paying the appropriate fee. I understand that my medical record will be kept for seven years after the date of my last visit. I understand that information from my medical record may be analyzed for research purposes, and that my identity will be protected and kept confidential. I understand that any questions I have will be answered by my physician to the best of her ability.

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