Patient Request to Access Protected Health Information (PHI)
Patient Request to Access PHI form.
This completed form is required for us to release your prescription data for your tax filing information, etc.
The fastest way to get this information is to create an account in our Rx Refill module. Then you can have automatic access to your profile. You can then print out your own tax information directly and immediately.
WORD DOCX form
1 page, b/w, 17k DOWNLOAD NOW
1 page, b/w, 69k DOWNLOAD NOW
2. Print out the form. Fill it out.
3. Return via:
Postal Mail: 825 SE Bishop Blvd, Ste 301, Pullman, WA 99163
or Fax: Fax number goes here
Scan the printed, filled out form and email the image file as an attachment to:
4. Please include how you want us to send the return information: postal mail, fax, email, or if you’ll pick it up at our office.
If you create an account in our Rx Refill module, you’ll have automatic access to your profile and can print out your own tax information immediately. That is the fastest method.