Forms Required for All Patients

  • Consent to Treatment - General

    • Explains services I provide, potential benefits/ risks, alternatives, patient rights and responsibilities, and confirms your voluntary consent to treatment. [Requires four sets of initials + signature.]

  • Notice of Privacy Practices - Acknowledgment

    • Confirms that you received the HIPAA Notice of Privacy Practices document (the actual document will be in Patient Documents). [Requires signature only.]

  • Practice Policies

    • Outlines general practice policies (eg. scheduling, cancellation/no-show/late arrival, prescriptions, coordination between visits, communication, after-hours/emergency guidance, etc). [Requires multiple initials, your communication preferences, + signature. This is the longest form.]

  • Telehealth Consent

    • Explains how telehealth works, technology considerations, risks, location requirements (i.e. Oregon only), and gives consent for remote care. [Requires signature only.]

  • OHP Financial Agreement (patients with CareOregon/OHP)

    • Explains the general billing and payment process for patients enrolled in OHP/Medicaid. [Requires insurance plan name, member ID, + signature.]

  • Insurance Verification Worksheet (patients with commercial insurance plans)

    • Provides a step-by-step guide to help patients navigate the process of calling their insurance plan to verify coverage, out-of-pocket costs, and specific benefits for visits with Dr. Heidi Wilson. [Requires filling in details about your insurance plan and benefit details provided by insurance representative.]

Instructions For Completing The Insurance Verification Worksheet:

The worksheet itself is sent to you as a Questionnaire through the Charm portal and includes instructions. I’m including additional information and instructions here so that this page could be open in one tab as a reference and the Charm Questionnaire could be open in another tab.

How to Use the Worksheet:

The Questionnaire is broken up into sections. A few sections can be completed ahead of time and a few of them may not be required depending on your insurance situation.

Collapsible Sections

  • Most sections of the worksheet are collapsible when completed within Charm as a questionnaire.

  • You can expand sections as you need them and hide sections you’re not using. If forms tend to feel overwhelming, this can help reduce visual clutter and make the form feel more manageable.

  • [Note: Collapsing a section will not erase your responses.]

Step-by-Step Guidance

  • The worksheet is designed to walk you through the whole process step by step to reduce the cognitive and emotional effort these types of phone calls can take.

  • The “Before You Call” steps can help you prepare so the call itself goes more smoothly.

Before You Call:

  • Gather your insurance card(s).

  • If available, log in to your insurance app or member portal, as it may contain information that isn't on your insurance card.

  • If possible, use a computer instead of your phone to complete the worksheet in Charm. That way, you can easily fill out the worksheet while you're on the phone with the insurance company. If you don’t have access to a computer or a second device, let me know and we'll figure out an alternative.

Sections to complete before calling:

These sections can be completed using information from your insurance card or insurance member portal.

  • Section 1: Patient Info & Call Setup

    • Includes the phone number you’ll be calling, which should be on the back of your insurance card (often “Customer Service” or “Member Services”).

  • Section 2: Insurance Plan Details - insurance plan name, ID number, group number, plan type, etc.

  • Section 3: General Medical Benefits - You may be able to fill in some of this section using your insurance card or portal, but plan to confirm it with the insurance rep so you can correct it if needed.

    • This section is about your general medical benefits, NOT naturopathic medicine-specific coverage.

    • e.g. deductible info, out of pocket max, primary care vs specialist costs, both in-network and OON.

  • Section 6: Secondary Insurance - This section requires that you select “yes” or “no.” If you have a secondary insurance plan, fill out this section before you call.

    • When you have more than one health insurance plan, one is your primary insurance and the other is your secondary insurance. Both insurers need to know about each other so claims can be processed correctly, and to help prevent delays, denials, and unexpected bills.

    • If you have a secondary insurance plan, fill out this section before you call.

Other Preparation Tips: 

  • Skim the form in its entirety to get oriented to the form and what you’ll be asking about.

  • Set an intention for the call: to allow yourself to pause, ask questions, or request clarification as needed. (You're not expected to be an insurance expert.)

During the Call:

General Tips:

  • Use this worksheet to guide the conversation and record the rep’s answers in the fields provided.

  • If a question or field doesn’t apply to you or your plan, write “N/A” rather than leaving it blank, when possible.

  • Include “$” or “%” when entering copay or coinsurance amounts.

  • Fields marked with a red asterisk (*) are required.

Sections to Complete or Review During the Call:

  • Section 3: General Medical Benefits - Verify your general medical benefits

    • e.g. deductible info, out of pocket max, primary care vs specialist costs, both in-network and OON.

    • Also confirm your annual reset date, i.e. when your deductibles and out-of-pockets maximums reset each year.

  • Section 4: Naturopathic Physician (ND) Visits - Ask if office visits with NDs are covered under your plan at all.

    • If ND visits are covered, you’ll skip ahead to Section 4a or 4b, based on my current network status with your insurance plan.

      • To confirm if I am in-network with your specific insurance plan, you can provide the insurance rep with the NPI(s) below:

        • Dr. Heidi Wilson - Individual/Rendering (Type 1) NPI: 1730430612.

        • If needed: Organization/ Billing (Type 2) NPI for Curio Integrative Mental Health LLC: 1295691244.

      • Section 4a: In-Network ND Coverage - Complete this section if I am in-network with your insurance plan

      • Section 4b: Out-Of-Network ND Coverage - Complete this section if I am NOT in network with your insurance plan.

      • You only need to complete the section that matches Dr. Wilson's current network status. However, if you'd like both in-network and OON coverage information for future reference, you're welcome to complete both sections, but this is optional.

  • Section 5: Labs & Imaging - Ask if labs and imaging are covered when ordered by an ND

  • Section 6: Secondary Insurance - If you have more than one active insurance plan, ask the insurance rep if they have your secondary insurance on file (this is required for coordination of benefits).

  • Section 7: Insurance Rep Info (optional) - record the insurance representative’s name and the call/reference ID.