Consent for Involvement In Care

In order to comply with specific rules regarding HIPAA, we ask that our patient complete and sign this privacy and security of health information. Unless this Form is completed, we cannot talk to anyone but you.

Billing and Payment Information
I, , herby authorize Integrative Pain Center of Alaska, LLC billing department to speak to the person(s) listed below regarding my billing and payment information.

1. relationship to patient
2. relationship to patient

Medication Information
I, , herby authorize Integrative Pain Center of Alaska, LLC to release prescription that need to be picked up on my behalf to the person(s) listed.

1. relationship to patient
2. relationship to patient

Appointment Reminders
I, , herby authorize Integrative Pain Center of Alaska, LLC and staff to leave appointment reminders by the following methods.

1. Home Telephone/ VoicemailYes No N/A
2. Work Telephone/ VoicemailYes No N/A
3. Cellular Phone/ VoicemailYes No N/A

I understand and assume responsibility of notifying IPCA whenever the listed information changes. I understand this release excludes; insurance companies, attorneys and other health care providers.

PATIENT’S SIGNATURE:
DATE:

WITNESS/ STAFF SIGNATURE:
DATE: