Intake Form

When a provider calls the PCL, a health navigator asks a brief series of questions about the caller and the patient they are calling about. Most of the questions are reporting requirements as determined by the Washington State Health Care Authority. The more history and information we have about the patient the better, but we will assist you using whatever information you have. Ideally, callers will have the following information available when they call:

Provider information asked

  • Provider first & last name
  • Direct phone (in case call is lost)
  • Email (for sending the written summary of the call)
  • Credential (ARNP, PA, MD, etc.)
  • Where do you work? (type of work site and name of work site)
  • City and County of practice
  • How did you hear about the PCL?

Patient information asked

  • Patient first and last name
  • DOB
  • Gender
  • City of residence
  • On Medicaid?
  • Any insurance coverage?
  • Race, if known
  • Ethnic group and Ethnic background, if known