WELLNESS CARE PLLC

Welcome to Wellness Care PLLC

  • Mental / Telehealth Services-424-396-1521
  • Wellness Care PLLC Serving in Washington and Arizona
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Chronic Care Management (CCM) Consent Form

Please read each statement and indicate your agreement by checking “Yes” or “No.”

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Do you consent to participate in Chronic Care Management (CCM) services, which involve ongoing support for your chronic health conditions, including regular check-ins and care coordination?
Do you understand that CCM services may be provided remotely through telephone or telehealth communication by a qualified healthcare provider?
Do you agree to allow your healthcare provider to access and share your medical information with other members of your care team as needed for coordination of care?
Do you understand that only one provider can bill Medicare (or your insurance) for your CCM services each calendar month, and you will notify your provider if you choose to stop or switch providers?
Do you consent to being contacted regularly as part of your care plan and acknowledge that you may withdraw from CCM services at any time by notifying your provider?

HIPAA Privacy Authorization Form

Authorization for Use or Disclosure of Health Information

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Purpose of Authorization: This form authorizes the use and disclosure of my protected health information (PHI) for purposes of treatment, payment, or healthcare operations as required to provide medical services. Information to Be Disclosed (check all that apply):
Patient Rights: I understand I may revoke this authorization at any time in writing. I understand this authorization is voluntary and that my treatment will not be conditioned upon signing this form. I understand that information disclosed under this authorization may be re-disclosed by the recipient and may no longer be protected by HIPAA. Expiration: This authorization will expire:

At Wellness Care PLLC, we are dedicated to providing comprehensive and compassionate healthcare to families across Washington and Arizona. As a family practice specializing in telehealth, we understand the importance of accessible and convenient medical care, especially in today’s fast-paced world. Our mission is to empower patients by offering expert guidance and support in managing chronic conditions, enhancing mental health, and achieving overall wellness.

Services

Get In Touch

  • (424) 396-1521
  • 7100 fort dent way , ste 220, Tukwila wa 98188
  • 20551 N. Pima Road PMB 1018 Suite 200 Scottsdale, AZ 85255 United States
  • PMB2028 19125 Northcreek Parkway, Suite 120 Bothell, WA 98011 United States
  • mwalker@wellnesscarepllc.com

Opening Hours

  • Sunday - Closed
  • Monday - 10:00 AM - 3:00 PM Open
  • Tuesday - 10:00 AM - 6:00 PM Open
  • Wed - 10:00 AM - 6:00 PM Open
  • Thurs - 10:00 AM - 6:00 PM Open
  • Fri - Closed
  • Saturday - Closed

@Copyrights Wellness Care Pllc 2025. All rights reserved

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