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

Notice of Privacy Practices Acknowledgment

Translate:

Fill-out the form below and then print it out. Your information will not be saved or sent.

Pullman Family Medicine has a responsibility to protect the privacy of your health care information and to provide a Notice of Privacy Practices that describes how your health care information may be used and disclosed, how you can access your health care information, and whom to contact if you have questions, concerns, or complaints.

We may change the Notice of Privacy Practices at any time, and you may contact our Privacy/Compliance Officer at 509-332-3548 to obtain a current copy of the Notice of Privacy Practices or to ask questions.

By my signature below, I agree that I have been offered the Notice of Privacy Practices of Pullman Family Medicine.

Printed name of patient
Patient’s Date of Birth
Patient or legally authorized individual’s signature
Date
Time
Printed name if signed on behalf of the patient
Relationship (parent, legal guardian, personal representative)
This form will be retained in your medical record.

For Office Use Only

Office staff complete below:

I have attempted to obtain the patient’s signature on this form, but was not able to obtain it for the reason(s) listed below:

Date:
Staff member initials:
Reasons: