Ackowlegement of notice of Privacy Practices - Southwest Ohio Pain Institute

Acknowledgement of Notice of Privacy Practices

Patient Name(Required)

First Name Middle Name Last Name

I have seen a copy of the Notice of Privacy Practices for Southwest Ohio Pain Center, located at the reception desk. I am aware that it details how my health information may be used and disclosed under federal and state laws. I understand that a personal copy of this notice is available upon request.

Patient/ Legal Representative Signature

Date

I authorize Southwest Ohio Pain Center, to release my healthcare information to the person/ persons listed below, in addition to referring physician and any other parties as required by Ohio state law.

Name of person

Telephone Number

Date

Information(Required)

The following information can be left on my answering machine/ voice mail if you are unable to reach me personally: Appointment reminders and call back reminders.

Information(Required)

I authorize Southwest Ohio Pain Institute to take my photograph to be used in conjunction with their electronic medical records for identification purposes.

Information(Required)

I agree to submit to a urinalysis for the purpose of testing for drug metabolites. The specimen provided is my own and has not been substituted and no alterations were made.