Palouse Pediatrics has offices in both Pullman, Washington and Moscow Idaho

TEST 2

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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):

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: __________________________________________________

 

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