HIPAA Acknowledgement

(print form)

Patient Name:____________________________________
Date of Birth: __________________________

PATIENT’S REPRESENTATIVE AUTHORIZATION

In accordance with new federal regulations we are not allowed to discuss or even acknowledge that you are a patient of Desert Pain Institute without your expressed written consent. If there is anyone (i.e.: spouse, parent, child, neighbor, etc.) you think might ever have a need to discuss your medical condition, your treatments, your appointments, or your financial account please list them below. This will prevent us from having to get your written consent each time they call to handle matters on your behalf.

Mark each purpose for which you are authorizing your protected health information to be used and/or disclosed to the person(s) you list below.

__ Discussion of financial account
__ Discussion of medical status
__ Discussion of scheduling appointments
__ Other: Picking up Prescriptions

1) Name: Relationship to patient:

2) Name: Relationship to patient:
This authorization will expire when I have been discharged from Desert Pain Institute and all financial matters are settled.

I understand that I may revoke this authorization at any time by giving written notice to the front desk staff. However, I understand that I may not revoke this authorization for any actions taken before receipt of my written notice to revoke this authorization.

________________________________ ________________
Patient's Signature                                    Today's Date

ACKNOWLEDGEMENT OF RECEIPT OF DESERT PAIN INSTITUTE’S
NOTICE OF PRIVACY PRACTICES

*You May Refuse to Sign This Acknowledgement*

I have been allowed to review and/or have received Desert Pain Institute’s Notice of Privacy Practices.

___________________________________________ Today’s Date:__________
Patient’s Signature or legally authorized individual

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For Office Use Only

Desert Pain Institute could not obtain a written acknowledgement of receipt of our Notice of Privacy Practice due to the fact:

__ Individual refused to sign
__ Communication barriers prohibited it
__ An emergency situation prevented us
__ Other (please specify)

________________________________ ________________
Employee Signature                                  Date