I, (Printed Name of Patient)
allow, (Full Name & Relationship to Patient)
to access my medical records until, (Month/Day/Year)
If I choose to end this consent before the expired date, I must contact Pullman Family Medicine and ano6ther form must be completed.
Please initial each area this access includes:
Billing & Payment Information
Health Information from other providers
Under Washington Law, the following areas of the medical record require specific authorized consent. Please initial below to authorize access to these protected areas of your medical record if you wish for them to be included in this authorization.
Mental Health/Psychiatric Disorders/Depression/Anxiety
Sexually Transmitted Disease (STD): Testing, Results, Treatment, or Symptoms
Substance Abuse/Use, Drug and/or Alcohol Abuse/Use
Below must be signed in front of a clinic staff member.
By signing this form, I acknowledge that this is optional and I am doing this of my own free will.
Clinic Staff Witness-Printed Name