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 Release Personal 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:
I request and authorize:
Name:
Address:
Phone or Fax:
-
To release health care information of the patient named above to:Palouse Pediatrics, Pullman1205 S.E. Professional Mall Blvd. Suite 104Pullman, WA 99163Palouse Pediatrics, Moscow1420 S. Blaine St, Suite 5Moscow, Idaho 83843
My Authorization:
You may disclose the following health care information:
Check all that apply:
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):
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
Patient or legally authorized individual signature
Date
Printed name if signed on behalf of the patient
Relationship