Patient’s Name: _____________________________________________ Date of birth: _______________
Current Address: _______________________________________________________________________
Previous Name: ________________________________________________________________________
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):
□ HIV (AIDS virus) □ Sexually transmitted diseases
□ Psychiatric disorder/mental health □ Drug and/or alcohol use
You may disclose this health care information to:
Name (or title) and organization or class of persons: ___________________________________________________
Address: _______________________________________ City: ________________________ State: ____ Zip: _____
Reasons for this authorization (check all that apply):
□ At my request
□ Leaving the area
□ Changing physician
This authorization ends in 90 days from the date signed, or:
When the following event occurs: __________________________________________________
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