Palouse Medical’s Patient Forms
Would you like to get a head start on the paperwork we will need before your next appointment? You have come to the right spot! Just give us a call to schedule your appointment. We look forward to meeting you!
New Patients click here.
Please Download. Print. Complete. And, Return the Following Forms.
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
Patient Profile:
This provides us contact information and patient demographics
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
Personal Health History :
This form is completed by new patients and those (ages 16 and older) who are returning for yearly physical exam
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
Flex Spending: OTC Reimbursement Request:
This is Palouse Medical’s general form for patients to complete to receive reimbursement for Over-The-Counter (OTC) medical expenses from flex spending plans. Check with your Flex Spending plan to verify that this form will work, as Palouse Medical can not guarantee that your Flex Spending plan will accept this generic form.
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
Medical Records Authorizations
Below are two links that will help keep your medical records current and managed. Please choose the appropriate form and click on the attached link. This will open a window with a PDF file containing the authorization you need.
Important Notice:
You may choose to fax, mail or bring this document in personally; however, we must obtain the signature of the individual(s)/legal guardian of the medical records in question before we can process the request. Thank you for understanding and your cooperation.
Form A – authorizes us to release your medical records or health information to a designated individual or an external health care provider.
Form B– authorizes us to request your medical records or health information.
_________________________________________________________________________________________
Please return form to our Pullman office at this address:
Palouse Medical
825 SE Bishop Blvd. Suite #200
Pullman, WA. 99163
Fax Number: 509-334-9247
