Well Coast Medical Corporation


582 Market Street, Suite 500, San Francisco, CA 94104 | 1455 Frazee Road, Suite 500, San Diego, CA 92108 | 6080 Center Dr. 6th Floor, Los Angeles, CA 90045 | 2175 NW Raleigh Street, Suite 110, Portland, OR 97210 | 1500 SW Chandler Avenue, Bend, OR 97702 | T: (833) 931-1716. F: (877) 448-3551HIPAA Statement

Patient Supplementary Forms

Please use the Patient Portal to communicate with your provider. Use this Supplementary Form to:  

Update Insurance |  Update Credit Card |  Authorize Release/Exchange of Information | Upload Documents | Complete Psychological Instruments

For ADHD Evaluations, DO NOT use this Form. Instead, please go to:  bit.ly/welladhd (Patient) OR bit.ly/welladhdo (Patient's Observer) 

IMPORTANT: THIS FORM IS NOT MONITORED IN REAL TIME.  DO NOT USE THIS FORM TO COMMUNICATE EMERGENCIES. For emergencies, call 9-1-1 or go to the nearest ER.  National Suicide Prevention Lifeline 800-273-8255