Patient Forms

Please click on a form below to download and print out.

New Patient Forms:

Registration Supplemental Form
PDF
Financial Policy
PDF
Electronic Communication Consent Form
PDF
NOPP Acknowledgement
PDF
Notice of Privacy Practices
PDF
Pt Rights & Responsibilities
PDF

Medical Records Forms:

Consent to Treat a Minor Information Sheet
PDF
Consent to Treat a Minor
PDF
Authorization to Use 
and Disclose Medical Information
PDF
Revocation of Authorization
to Use or Disclose
PDF
Permission to Access Medical Records
PDF

Visit Specific Forms:

Motor Vehicle Accident Claim Form
PDF



Palouse Pediatrics is a proud member of the Pullman Regional Hospital Clinic Network.

PULLMAN
1205 S.E. Professional Mall Blvd. Suite 104
Pullman, WA 99163
(509) 332-2605
FAX: (509) 334-5754
Email UsDirections
MOSCOW
1420 S. Blaine St, Suite 5
Moscow, ID 83843
(208) 882-2247
FAX: (208) 882-2292
Email UsDirections

Palouse Pediatrics complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. View our policy here.

Pullman Regional Hospital Clinic Network, DBA Palouse Pediatrics complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

© 2018. PULLMAN REGIONAL HOSPITAL CLINIC NETWORK.
linkedin facebook pinterest youtube rss twitter instagram facebook-blank rss-blank linkedin-blank pinterest youtube twitter instagram