PHONE: (509) 878-1890
FAX: (509) 530-2863

Patient Forms

Please click on a form below to download and print out.

New Patient Forms:

Patient Registration Form - Adult
PDF
Patient Registration Form - child
PDF
Notice of Privacy Practices Acknowledgement
PDF
Health History Questionaire
PDF
Patient Rights & Responsibilities
PDF
Financial Policy
PDF

Medical Records Forms:

Authorization to Use
and disclose medical information
PDF
Permission to Access Medical Records
PDF
Consent To Treat A Minor
PDF

Visit Specific Forms:

Motor Vehicle Accident Claim form
PDF
Annual Wellness Visit
PDF
Department of Transportation Physical
PDF
Sports Physical Examination Form
PDF

Pullman School District Medication Authorization Forms:

School Asthma Plan
and Medication Orders
PDF
Authorization for Administration
of Medication at School
PDF
Severe Allergic Reaction Plan
and Medication Orders
PDF

Palouse Health Center is a proud member of the Pullman Regional Hospital Clinic Network.

BUSINESS & MAILING ADDRESS
Mailing: 588 SE Bishop Blvd, Ste B
Pullman, Washington 99163
Billing Address: 840 SE Bishop Blvd, Ste 101
Pullman, Washington 99161
(509) 878-1890
FAX (509) 530-2863
Email UsDirections

Palouse Health Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. View our policy here.

Pullman Regional Hospital Clinic Network, DBA Palouse Health Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

© 2020. PULLMAN REGIONAL HOSPITAL CLINIC NETWORK.