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Forms

Patient Registration Form

     Patient information, insurance information, financial agreement, Omnibus Budget Reconciliation Act, payments of benefits  authorization, and automated telephone system authorization.

Medical History Form

     This form asks you to list your medications, allergies, any symptoms you're experiencing, preexisting problems or conditions that you have, family health history, and surgeries performed.

Standing Authorization To Verbally Disclose My Health Care Information

     Authorization to verbally disclose health care information to persons that you list.  This authorization only covers verbal disclosures.  Washington State law (RCW70.02) requires that a written authorization be signed for releases of protected health information other than verbal disclosures, and a written authorization of that type is only good for 90 days.

Notice of Privacy Practices Acknowledgement

     Olympia Multi-specialty Clinic respects your privacy.  We understand that your personal health information is very sensitive.  We will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so.

Medical Records Release

     Authorization to use or disclose your health care information.  You do not have to sign this authorization in order to get health care benefits (treatment, payment or enrollment).  However, you do have to sign an authorization form to:

  • Take part in a research study or
  • To receive health care when the purpose is to create health care information for a third party.