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

Authorization To Use Or Disclose Protected Health Information

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Fill-out the form below and then print it out. Your information will not be saved or sent.
Patient Name:
Previous Name(s):
Phone:
-
Date of Birth:
Social Security #:

Information to be released:

All health care records in last 3 years and pertinent chart information (i.e. Immunization Record, Growth Charts, Op Notes)
All health care information related to the following treatment/condition:
Vaccines/Immunizations
The following protected areas of healthcare records require specific authorization and will be excluded from the information released unless specifically authorized below. I request that the following information be included in this medical release (please check each line you wish to be included);
Purpose for release (at least one box MUST be checked):
Other:

Information to be released FROM:

Name/Title/Organization:
Address:
Phone:
-
Fax:
-
Attn To:

Information to be release TO:

Name/Title/Organization:
Address:
Phone:
-
Fax:
-
Attn To:

Completion of this request can take up to 15 business days from date of receipt.

My Rights:

I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment or enrollment).  I may revoke this authorization in writing.  If I did, it would not affect my actions already taken by Pullman Family Medicine, PLLC based upon this authorization.  I may not be able to revoke this authorization if its purpose was to obtain insurance.  Once health care information is disclosed, the person organization that receives it may re-disclose it.  Privacy laws may no longer protect it.

This release shall expire on: (PLEASE SELECT ONE ONLY)

Specific date:
90 days from today
Specific event:
1 year from today
Patient or legally authorized individual signature
Date
Time
Printed Name
Relationship to patient