Pullman Family Medicine
915 NE Valley Rd
Pullman, WA 99163
Phone: (509) 332-3548
Fax: (509) 332-5253

Permission to Access Medical Records

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Fill-out the form below and then print it out. Your information will not be saved or sent.
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:
Appointment Information
Billing & Payment Information
Health Information from other providers
Diagnosis
Treatment
Symptoms
Test Results
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.

Printed name of patient
Date of Birth
Patient Signature
Date and Time
Clinic Staff Witness-Printed Name
Date and Time