Forms


 

New Patient Information and Forms


Second Opinion 100

We invite an email to staff@opas.us with a request for a Second Opinion 100 by Dr. Rotchford. Our scheduler will be in touch to assure a convenient time, possibly evenings and weekends, for an appointment by phone or telemedicine. A fixed fee of $100 applies. One does not need to be an established patient to benefit from this service. Prescriptions will not be written, however, unless a patient has been seen in the office, or we have been given the opportunity to review the medical history and complete a more thorough baseline.

Examples of conditions likely to benefit from second opinions (particularly if current care or recommendations have significant side effects or limited benefit) include: chronic pain management, substance use disorders, brain health, cancers, bone thinning, surgery for painful conditions, PTSD, auto-immune related conditions, regional referrals, etc.. Dr. Rotchford is also an acknowledged expert in the role of acupuncture & Chinese herbs. One might also visit the Handouts Tab for further ideas about how Dr. Rotchford might be of service.


SCHEDULING AN APPOINTMENT
To schedule an appointment please call 360-385-4843.


INTAKE FORMS: please see below for links to forms that can be faxed securely to us, mailed or simply brought in at time of appointment.


NOTICE to Potential Patients who have state administered insurance: Medicaid, Apple Health, Basic Health, L&I, etc. If you have a state administered health plan, please click the following link: Memo about Washington State plans.

If you are a Medicare recipient IMPORTANT to read MEMO To Medicare Patients regarding Opt-Out Status. As of January 1, 2019 Dr. Rotchford is opting-out of Medicare and based on Medicare law will require Medicare patients to sign a contract to assure they are aware that his professional services (not what he orders or authorizes) are not covered by Medicare.


YOUR FIRST VISIT
After the physician listens to your medical history and provides a pertinent physical exam, he/she can advise you of your health care choices. We expect new patients to feel well listened to. Our plans for pain management and addictions are intended to be practical and workable. For your first visit expect to be at the office for at least an hour. Please do not expect to have prescriptions for controlled substances filled during the first consultative visit.


PAYMENTS AND INSURANCE
Please follow the Link to the Memo Describing Policies Regarding Commercial Insurance Coverage. We do continue to bill third parties but with specific caveats.

Medicare Opt Out information and contract for patients

Payment by cash, checks, or credit card is expected at the time of the visit unless other arrangements have been made. While we are prepared to help bill third parties we do not have any formal agreements with private insurers.


AFTER HOURS CARE
A physician is available by phone, generally within 24 hours, for established patients encountering concerns regarding their treatment plan. Please call the office number 360-385-4843 for instructions on how best to contact our physician. If it is acute or new medical issue please call your PCP first. Dr. Rotchford available for issues related to his prescriptions and associated chronic conditions.


FORMS RELATED TO YOUR FIRST VISIT
These forms can be printed out and then completed and returned via mail, fax, or in person. If reading skills or other issues preclude one's ability to complete these forms please let the receptionist/scheduler know. The forms marked with a "*" are especially helpful to be completed or reviewed prior to your first visit.


* NEW PATIENT PACKET - May be downloaded and is set up to be printed on two sides. Please complete and sign where indicated to be seen as a new patient. The packet includes:
Welcome Memo
Demographics - Intake form
Brief Medical History Questionnaire
Payment Policies


OTHER HELPFUL FORMS AND HANDOUTS For New and some established patients:
Notice of Privacy Practices (Please Read and sign acknowledgement form at end)

Release of Healthcare Information (useful for records to be sent from one provider to another)

Memo for Patients who are interested in specialized medical care for pain management and substance use disorders

Policies regarding prescription refills and prior authorizations

Out of Network Commercial Insurance Related Issues


QUESTIONNAIRES
The following are some questionnaires we often provide to new patients who are being see for pain management or addictive disorders:
Pain and Activity Questionnaire
Patient Health Questionnaire (PHQ) (Screens for depression)
AUDIT Alcohol use screener
GAD-7 Anxiety Screener
Stressful Life Events
PCL-5 PTSD screener
COMM Screen for assessing opioid risks


AGREEMENTS AND CONSENT FORMS
The following two forms are the agreements/consents related to the use of prescribed controlled substances. If you are considering having us prescribe you any controlled substance, please review and be prepared to sign the agreement. If you are wanting to be prescribed an opioid such as buprenorphine, morphine, oxycodone, tramadol, etc. please also review and be prepared to sign the opioid use agreement:

OMS Controlled Substance Use Agreement
General Opiate/Opioid Information Sheet & Consent

Location
J. Kimber Rotchford, MD
1136 Water Street, Suite 107
Port Townsend, WA 98368
Phone: 360-385-4843
Fax: 360-379-1441
Office Hours

Get in touch

360-385-4843