NEW PATIENT & YEARLY FORMS
Complete the necessary paperwork for you next appointment ahead of time. You may choose to return the forms to our office by mail, fax, or can bring them to our office.
Click the forms below to open a pdf version
Form #1: Patient Profile
- Initially completed by new patients, as it allows us to create your patient account
- Completed annually for billing purposes
- Updated when patients have experienced a name change or have new contact information
Form #2: Personal Health History
- Initially completed by all new patients
- Completed annually with physical examinations
- Completed whenever you establish care with a new primary care provider
Form #3: Patient Privacy Notice
- In compliance with HIPAA, this notice is provided to all patients
- Please read this document prior to signing the privacy notice section on the patient profile
This form authorizes us to request or release your medical records or personal health information to a designated individual or an external health care provider. This form can be used for requesting and disclosing protected health information. Some individuals use this form to authorize caregivers and loved ones with permission to visit with Palouse Medical to help assist with care needs. Other people use this to ensure that Patient Portal Accounts that are linked (providing access to chart information) and that Palouse Medical has permission to disclose information to one linked account.
BEFORE THE REQUEST CAN BE PROCESSED, each section must be filled out and we must obtain the signature of the individual(s), medical POA, parent or legal guardian*
*If we do not have the POA paperwork on file, we will need it to process the request. We may also request proof of guardianship depending on the circumstances.
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. Please check with your Flex Spending Plan administrator to verify that this form will work, as Palouse Medical can not guarantee that they will accept this generic form.