Forms & Policies

Interested in seeing us?

Before your first appointment

Before your first appointment, we will send you a copy of all our forms for digital signature. You will be provided a copy of your signed new patient forms. If you would like to review our forms, we have copies of our forms below.

FFS Patient Agreement_10Nov2022.pdf

Fee for Service Agreement

This form is the fee for service legal agreement between patients and our providers

Patient Privacy Practices.pdf

Notice of Patient Privacy Practices

This form explains our privacy practices

Release of Information from PCP.pdf

Release of information to talk to your PCP

This form lets us communicate about the care you receive at Lavender Spectrum Health with your PCP. Patients are required to have a PCP with whom you are comfortable for Lavender Spectrum Health to speak with on your behalf in order to receive our services.

Attendance Policy

Here at Lavender Spectrum Health, we strive to help as many patients as we can with their unique healthcare needs. One factor in being able to provide continuous care is punctual patient attendance of all scheduled appointments. This helps us keep our facility running and see all patients in a timely manner.

1) 24 hours’ notice is required to cancel or reschedule any appointment. The exception is emergencies, which will be decided on a case-by case basis using provider discretion.

2) If an appointment is canceled with less than 24 hours’ notice or is a no-show, you are responsible for paying a $70 fee. This is not applicable to patients with WA Medicaid/ AppleHealth. Insurance companies other than WA Medicaid/ Apple Health do not pay for no-shows or late cancellations, but allow us to charge for them. If you are unsure if this policy applies to you, you can ask us and we are happy to tell you.

3) If you are more than 10 minutes late to an appointment, you may be charged the $70 fee and/or lose the appointment. The final decision will be up to the discretion of your provider. This is not applicable to patients with WA Medicaid/ Apple Health or Medicare.

4) Late cancellations, no-shows, and tardiness harms other patients who are unable to receive care due to scheduling inefficiencies. For this reason, we reserve the right to discontinue care for patients that repeatedly violate our appointment policy.

5) If our attendance policy is violated by a patient three (3) times in a calendar year, the patient may be discharged from our practice. The provider’s discretion shall be determinative of when discharge is appropriate and the provider may accelerate this policy on a case-by case basis.