Palouse Pediatrics

Palouse Pediatrics, Pullman
1205 S.E. Professional Mall Blvd. Suite 104
Pullman, WA 99163 (map)
Phone: 509-332-2605
Fax: 509-334-5754

Palouse Pediatrics, Moscow
1420 S. Blaine St, Suite 5
Moscow, Idaho 83843 (map)
(Located in Eastside Market Place)
Phone: 208-882-2247
Fax: 208-882-2292

Authorization to Disclose Protected Health Information

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Fill-out the form below and then print it out. Your information will not be saved or sent.

Patient’s Name:
Date of birth:
Current Address:
Previous Name:

My Authorization:

You may disclose the following health care information (check all that apply):

All health care information in my medical record
Health care information in my medical record relating to the following treatment or condition:
Health care information in my medical record for the date(s):
Other: specify date(s):

You may use or disclose health care information regarding testing, diagnosis, and treatment for:

Check all that apply

You may disclose this health care information to:

Name (or title) and organization or class of persons:
Reasons for this authorization (check all that apply):

This authorization ends in 90 days from the date signed, or:

When the following event occurs:

My Rights:

I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment or enrollment).

However, I do have to sign an authorization form:

▪ To take part in a research study or

▪ To receive health care when the purpose is to create health care information for a third party.

I understand I may revoke this authorization by:

▪ Fill out a revocation form. A form is available from Palouse Pediatrics.

▪ Write a letter to Palouse Pediatrics SE 1205 Professional Mall Blvd, Suite 104, Pullman, WA. 99163

Once health care information is disclosed, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.

Fees for copying records

I understand that I will provide this information within 3 business days from receipt of request, and I may be charged a fee for preparing and furnishing this information.

Patient or legally authorized individual signature:
Date:
Printed name if signed on behalf of the patient:
Relationship: