Now accepting Telehealth appointments. Schedule a virtual visit.

Forms


 

Forms, Questionnaires, and some basic office policies intended for New Patients

New Patient Packet as of November 2020

Please follow the link and print it out to complete.

You may return the forms by secure email (Ask our receptionist how) by fax, by mail, or by person at time of first visit. Included are a brief introduction to the practice, an intake demographic’s form, a brief medical history form, and a payment policy form. For those who have medicare coverage there is also the legal requirement for you to sign a Medicare Contract before being seen.

The above enclosed payment policy form reviews charges and third party billing concerns. Dr. Rotchford has very few agreements with third parties so be prepared to pay out of pocket or seek prior approval through you third party coverage.

Notice of Privacy Practices (Please Read and sign acknowledgement form at end)


Memo Regarding patients who seek specialized medical care for chronic pain and SUDS

This for patients who want ongoing care by Dr. Rotchford for Chronic pain issues or substance use disorders.  It is particularly pertinent for patients who might benefit from controlled substance prescriptions.    


Memo about Washington State plans.

This memo is directed to potential patients who have state administered insurance: Medicaid, Apple Health, Basic Health, L&I, etc.

 

REGARDING YOUR FIRST VISIT

After Dr. Rotchford listens to your medical history and provides a pertinent physical exam and reviews your records, he will advise you of suitable options. 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 your first consultation with Dr. Rotchford.

 

AFTER HOURS CARE

Dr. Rotchford 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 an acute or new medical issue please first call your PCP. Dr. Rotchford is available for issues related to his prescriptions and associated chronic conditions.

 

OTHER HELPFUL FORMS AND HANDOUTS For New and some established patients:

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

Policies regarding prescription refills and prior authorizations

Out of Network Commercial Insurance Related Issues

 

QUESTIONNAIRES

PAIN Questionnaires Packet for New Patients This includes questionnaires that look for comorbid issues that may be contributing to patients with any form of chronic pain.

 

AGREEMENTS AND CONSENT FORMS

The following two forms are the agreements/consents related to 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 expecting 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
1233 Lawrence Street, Suite 102 & 301
Port Townsend, WA 98367
Phone: 360-382-6244
Fax: 360-379-1441
Office Hours

Get in touch

360-382-6244