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Call: 1 (775) 689-5410
Home
Our Team
Services
About
Conditions Treated
Treatments Options
Physical Therapy
Diagnostic Tools
Referring Physicians
Patients
New Patients
Patient Resources
Insurance Information
Forms
Contact
Patient Portal
Personal Health Information and HIPAA
Comprehensive. Committed. Compassionate.
Authorization to release Personal Health Information and HIPAA Privacy Acknowledgement
Patient Name:
(Required)
DOB
(Required)
MM slash DD slash YYYY
ID#
(Required)
Patient Email
(Required)
Please fill in the following:
When contacting you we should:
Leave a message on your home answering machine/voicemail?
(Required)
Yes
No
Leave a message with a family member/member of your household
(Required)
Yes
No
Leave a message at your place of employment?
(Required)
Yes
No
Discuss your medical condition with a family member/member of your Household/friend/other?
(Required)
Yes
No
If yes, please list name and relationship:
(Required)
Release any of your medical information (office notes, lab reports, etc. &.) to a family member/member of your household/friend/other?
(Required)
Yes
No
If yes, please list name and relationship:
(Required)
Discuss your medical billing or insurance information with a family member/member of your household/friend/other?
(Required)
Yes
No
If yes, please list name and relationship:
(Required)
Are any of these people your Power of Attorney?
(Required)
Yes
No
If yes, who
(Required)
I authorize the release of my medical records to other physicians/healthcare providers?
(Required)
Yes
No
Please list:
(Required)
I hereby authorize Nevada Pain and Spine Specialists to obtain or release all pertinent information regarding my medical care, as needed, to assist in my ongoing treatment or from other health care providers, laboratories, radiology facilities or other institutions. Furthermore, I authorize the release of information to those family/friends listed above. This authorization remains in effect until revoked. I have reviewed and confirm the above information is true and correct and provide my consent regarding any and all above stated authorizations. I acknowledge that I have read and understand and have been offered a copy of the Nevada Pain and Spine Specialists Notice of Privacy Practices. I understand that Nevada Pain and Spine Specialists complies with all applicable Federal Civil Rights laws and does not discriminate based on race, color, national origin, age, disability or gender.
Signature of Patient/guardian
(Required)
Signature of witness (staff member)
(Required)
Name of Patient/ guardian
(Required)
Date
(Required)
MM slash DD slash YYYY
Name of witness (staff member)
(Required)
Date
(Required)
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.
