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  • Excelsior Wellness Center

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509-559-3100

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Program and Service Forms

 

REFERRAL FORMS FOR SPECIALTY PROGRAMS
  • Wraparound with Intensive Services (WISe+) Referral Form
AUTHORIZATIONS TO RELEASE INFORMATION FORMS
  • Records-Request-Form
  • Release of Information Form

CONSENT FORMS
  • Group Telehealth Consent Form
  • General Release of Liability Form
  • Telehealth Consent Form

 

  • Notice Of Privacy Practices
Excelsior Wellness Center
Main: 509-559-3100 ~ Fax: 509-588-7582
3910 W Indian Trail Rd. Spokane, WA 99208


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