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PLEASE BRING THE FOLLOWING TO YOUR SCHEDULED APPOINTMENT:
 MRI Films
X-Rays
Reports
List of all Medications that you are currently taking
Your insurance cards
Names and addresses of referring and primary doctors
Completed patient information forms
Failure to bring this information may result in your appointment being rescheduled.
The Health Insurance Portability and Accountability act of 1996 (HIPAA), protects health information created or maintained by health care providers throughout the United States.
Prior to receiving care in our office, each patient shall receive and be asked to acknowledge that they have received a Notice of Privacy Practices that explains their rights under HIPAA and our use of their health information for treatment, payment and health care operations without further authorization.
Also as part of the HIPAA regulations, each patient has the right, with some restrictions, to:
Review his or her own medical record;
Request an amendment or correction to the medical record;
Add supplemental information to the record;
Restrict use and disclosure of your medical information;
Authorize formal consent before health information is released other than for treatment, payment or as part of health care operations and
Know who requested and received medical information for other than treatment, payment, or health care operations
In protection of your information, Prima Pain relief and its employees are prohibited, with some exceptions, from releasing your health information to anyone not involved in your health care or in office operations, including family members, unless you have provided written consent. The Authorization for Release of Information form allows Premier Pain relief to release your information to a particular agency or individual that you designate.
Note: To view these forms you will need the free Adobe Acrobat Reader.
If you don't have it, download it now.
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