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Forms & Login

Harborview Long-Term Care Forms

Looking for an easy way to send us information about a new resident at your facility? Please download and complete the forms below and return them to us by fax. Alternatively, you may complete and submit the online Patient Intake form on this page instead of downloading and faxing it back. Please note that the Current Medications form must be downloaded and faxed back regardless of which option you choose for submitting the intake form.

Patient Intake Form (Download)
Current Medications Form (Download)

Secure login

From the Harborview Long-Term Care web portal, you can access information about your patient’s current medications, reorder meds, print MARs and Physician Order Sheets.

Login

New Patient: Long-Term Care Pharmacy

Patient Information

Name*
Address*
MM slash DD slash YYYY
Gender

Insurance Information

Contact Information

Contact Preference
(please separate multiple allergies with commas)
(please separate with commas)
(please separate multiple conditions with commas)
(enter 'None' if appropriate)
(for Medicare and Medicard enrollment)
Feel free to make comments.

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Refill a Prescription

Need a Prescription Refilled? Use our RxLocal Patient Portal.

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Kelley-Ross has been Seattle’s resource for innovative pharmacy services since 1925. We provide PCAB accredited compounding, ACHC accredited specialty pharmacy, innovative medication management, customized Long Term Care solutions and more.

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