New Patient Intake form

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Thank you for your interest in Healing Roots Medicine!

(Formerly Hearthside Medicine)

We provide exceptional in-depth root-cause focused medicine, integrating functional and integrative medicine with conventional medicine when needed. We can prescribe and order labs and advanced imaging when needed as well as offer supplement/nutritional options for common health concerns.

Once our staff get you set up in our system by 1-2 business days you should get an email from our Athena Health system saying you are registered.
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How did you hear about Healing Roots Medicine?(Formerly Hearthside Medicine)
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Which Insurance do you have?* This field is required.
Medicare or Medicare Advantage replacement plan
OHP, Medicaid, or Pacific Source Medicaid/Community Solutions
Tricare West
MODA
Providence
Regence Blue Cross Blue Shield
Pacific Source (Not Medicaid)
United
Aetna
HMA
Health Comp
Cigna
UMR
GEHA
First Choice
Health Net OR
Self Pay (No insurance)
Other
4
Some MODA plans require you to be seen by a "medical home" often referred as "MODA 360". Is your plan a MODA 360 plan?
YESNO
5
Some Providence plans require you to be seen by a "medical home". Does your plan require a medical home?
YESNO
6
We are sorry but we are currently at capacity for your insurance type and can not accept any new pateints at this time.

We know this can be hard however, you are welcome to check back next month to see if we have opened up again.
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Unfortunately your insurance requires a medical home and does not cover visits at our clinic. We do offer competitive cash rates which are $250 for 1st appointment and $175 for any follow up. Do you wish to proceed?
YESNO
8
We do offer competitive cash rates which are $250 for 1st appointment and $175 for any follow up. There may be additional charges for additional testing or services. Do you wish to proceed?
YESNO
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We are sorry your plan does not cover your visits at Healing Roots Medicine.

Next time your insurance is up for renewal consider opting for a package that does not require a medical home and we can try again at that time.

PacificSource is a local nonprofit insurance company that typically offers the best packages at the best prices for patients.

We wish you the best of luck but are happy you did not end up with a surprise bill after being seen.

Sincerely

Healing Roots Medical Team
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Hmmm, We may not be in network with your insurance plan. Please continue filling out your details and one of our representatives will reach out to you before your appointment to see if we are in network or not.
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Great News! We should be in network with yor plan.

Please select Next to continue signing up.
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Patient's Name* This field is required.
First Name
Last Name
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Patient's Date of Birth* This field is required.
Date
Month
Day
Year
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If patient is a minor, Parent's Name
First Name
Last Name
15
Email (To set up your patient portal)* This field is required.
example@example.com
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Address* This field is required.
Street Address
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City
State / Province
Postal / Zip Code
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The Bahamas
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Belarus
Belgium
Belize
Benin
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Bolivia
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China
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Cuba
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Democratic Republic of the Congo
Denmark
Djibouti
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Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
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Laos
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Mali
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Marshall Islands
Martinique
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Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
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South Africa
South Ossetia
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Suriname
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
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Turks and Caicos Islands
Tuvalu
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Uruguay
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
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Zimbabwe
Other
Country
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Phone Number* This field is required.
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Gender Identity
Female
Male
Transgender Female
Transgender Male
Genderfluid
Non-Binary or Gender Neutral
19
Assigned Gender at Birth
Please Select
Please Select
Male
Female
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Insurance Company & Plan NameCurrently closed to new Medicaid/OHP/Medicare & Tricare West patients. We take Pacific Source commercial plans, First Choice, United, Regence, Blue Cross Blue Shield, MODA (Not 360 plans), HMA, Health Comp, & Providence.
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Insurance Member ID & Group Number
22
Please take a Photo of your Insurance Card
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What do you need to be seen for?
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Ok
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Which provider would you like to see?Please check appropriate box(es):
Soonest Available Provider
Jeremy Brodhead, NP (Integrative medicine for Health optimization, Weight Loss, High Cholesterol, High blood sugar/diabetes, High blood pressure, Sport Medicine/Injuries, Men's Health and testosterone)
Havilah Brodhead, NP (Integrative & Functional Medicine for the following topics: Women's Health & Hormones, Menopause/HRT, Mental Health, Autoimmune, Cholesterol, high blood sugar, weight concerns, POTS, Gut Health/GI)
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What type of appointment are you wanting?OHP/Medicaid/Medicare are not eligible for Functional Medicine
Weight Loss
Men's Health/Testosterone/General Check-up
Sports Medicine/Sports Performance Optimization
Functional medicine (no primary care)
Functional Gut Health (SIBO, IBS, Diarrhea, Constipation, Heartburn, Celiac, Ulcerative Colitis, Crohn's)
Hormones : Hormone Replacement Therapy Only or Help with Natural Menopause Support
Women's Health (Irregular periods, endometriosis, fertility concerns) with Integrative Approach
POTS
Advanced Cholesterol Screening and integrative therapies
Diabetes/Prediabetes/Insulin resistance evaluation or integrative treatments (No Type I Diabetes)
Hashimoto's/Thyroid Disorder
Other Autoimmune disorder using Integrative Medicine Approach
I just want a whole Health Check up and Labs
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Next Steps to Schedule your 1st Appointment

Our staff will get you set up in our system by 1-2 business days and then you should get an email from our Athena Health system inviting you to register for the patient portal.

You can then convienently self schedule a new patient visit from the patient portal or "Athena Patient" app.

If you do not hear from us please feel free to call us.

You can usually get scheduled within 1-2 weeks!

New patient consents & health history questionnaires are done virtually via Txt ahead of your appointment.

You will recieve a text message 4 days and 1 day before your appointment.

We require these be done ahead of time please.
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Thank you for choosing Healing Roots Medicine!Formerly Hearthside Medicine
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