Patient Forms

New Patients:

Save time – complete your forms before you arrive for your appointment! You should bring a complete list of medications with you to your first appointment. If you have difficulty with any of the questions on any of the forms, fill out what you can, bring the form with you, and we will help you complete it. Please remember to bring your driver's license and insurance card. We will need to see a picture ID to make sure someone else is not using your insurance. A copy of your insurance card helps us bill your insurance correctly.

Privacy:

You have the right to ask for an Out-of Pocket Estimate for services provided in our practice:

If you are a Medicare patient and we believe the services you require are not covered by Medicare, you must fill out an ABN (Advanced Beneficiary Notice) form. This is our commitment to you to ensure you understand exactly how much your services will cost.

The Voiding Diary is to be competed upon physician request. For your convenience, you may print the diary by opening the voiding diary file:

Refund Policy:

Patient accounts with a credit balance will be reviewed. A refund will be issued if the investigation indicates this is appropriate. If the credit balance is the result of a posting error, the correction will be made and no refund will be issued.

When payments on an account create a credit balance, a thorough review of the account will be conducted to determine the cause of the credit balance. Credit balances will be resolved within 45 business days of the receipt of payment that generated the credit balance. This time frame will also include the amount of time necessary to issue a refund check, if appropriate.

Ambulatory Surgery Center:

If you would like to release your medical records from Washington Urology and Urogynecology Associates, PLLC to any other party, you must complete the Medical Records Release form:

Please note: If you would like to fax your forms ahead of time, our fax numbers are listed below:.

  • Bellevue Office and Surgery Center: 425-453-2827
  • Dr. Ernest Norehad's Office: 425-899-4649

Insurance Companies

Below you will find a list of insurance companies we are contracted with. If you do not see your insurance company on the list and want to ensure your insurance company will cover your services, please contact our billing department at 425-284-1116.

  • Aetna U.S. Healthcare
    • HMO
    • PPO
    • POS
    • EPO (Microsoft)
    • Golden Medicare
  • Cigna (All plans except HMO)
    • PPO
    • PSO
  • First Choice Health Network
    • PPO
    • POS
    • Triple Option
    • HMO
    • Costco
    • Boeing
    • HealthFirst
    • SeniorsFirst
  • Group Health Option (First Choice) & Alliant Plus
  • Labor & Industries (Standard)
  • Medicare
    • Standard
    • Railroad
    • MedAdvantage Plans
  • Humana
  • PHCS (FirstHealth)
    • PPO
    • POS
    • EPO
  • Premera Blue Shield
    • Participating
    • PPO
  • Providence
  • Regence Blue Shield
    • Participating
    • Preferred
    • Selections
    • FEP
    • Basic Health
    • RegenceCare
    • MedAdvantage
  • United HealthCare (PPO)
    • Secure Horizons
    • ARP