Patient Full Name *

Patient Signature

Date

Responsible/Authorized Representative (Guarantor):

Guarantor Signature

Clear

Relationship to Patient

Guarantor Date

I have received and reviewed a copy of this office's Notice of Privacy

Practices which describes how they use and disclose my health information and their HIPAA notice, which outlines standards and use of my protected health information.

Full Name

Signature

Clear

Date

Patient Name

Date of Birth

Many of our patients allow family members such as their spouse, parents or others to call and request medical or billing information. Under the requirements of HIPAA, we are not allowed to give this information to anyone without the patient's consent. If you wish to have your medical or billing information released to family members you must sign this form. Signing this form will only give information to family members indicated below.

I authorize Mind + Body Medicine and/or my physician to release my medical and/or billing information to the following individual(s):

1. Individual:

1. Relation to Patient

2. Individual:

2. Relation to Patient

3. Relation to Patient

Patient Signature *

Clear

Date *

Please check this box to acknowledge that you have read and accept the above *

Signature

Clear

Provider Signature

Clear

Medical Authorization to Treat and Obtain Confidential Information from Medical Records

Patient Name

DOB:

SS#

Patient's Signature *

Clear

Date *

patient Name *

Date of Birth *

Last 4 of SS#:

Phone *

Address

Street Address *

City

State

Country

Postal Code

Date(s) of Service(if known)

Other:

Description of the purpose of the use and/or disclosure:

Other:

Fax #

Name

Address

Phone #

Check Appropriate Delivery Method:

Mail 1

Fax (Healthcare Organization Only)

Pick-Up Records

Other:

I understand It will expire one year from the date of signature

When checked, I understand that the record is incomplete and additional documentation will continue to be added. I understand that I may request a complete copy at approximately 30 days post discharge.

Signature of Patient or Patient's Representative: *

Clear

Date *

Printed Name/Relationship of Patient's Representative:

Name of Patient: *

Date *

For female patients only:

To the best of my knowledge I am NOT pregnant.

If I am not pregnant, I will take appropriate precautions to avoid pregnancy during my course of treatment. I accept that it is my responsibility to inform my physician immediately if I become pregnant.

If I am pregnant or am uncertain, I WILL NOTIFY MY PHYSICIAN IMMEDIATELY.

I understand that, at present, there have not been enough studies conducted on the long-term use of many medication(s) to ensure complete safety of my unborn child(ren). With full knowledge of this, I consent to its use and hold my physician harmless for injuries to the embryo, fetus, or baby.

I certify and agree to the following (Patient Shall Acknowledge All Provisions by Checking Each Box):

I am not currently using illegal drugs or abusing prescription medication(s) and I am not undergoing treatment for substance dependence (addiction) or abuse. I am reading and making this agreement while in full possession of my faculties and not under the influence of any substance that might impair my judgment.

I have never been involved in the sale, illegal possession, misuse/diversion, or transport of controlled substance(s) (narcotics, sleeping pills, nerve pills, or painkillers) or illegal substances (marijuana, cocaine, heroin, etc.).

No guarantee or assurance has been made to me as to the results that may be obtained from chronic pain treatment. With full knowledge of the potential benefits and possible risks involved, I consent to chronic pain treatment, since I realize that it provides me an opportunity to lead a more productive and active life.

I have reviewed the side effects of the medication(s) that may be used in the treatment of my chronic pain. I fully understand the explanations regarding the benefits and the risks of these medication(s) and I agree to the use of these medication(s) in the treatment of my chronic pain.

If I become a patient in this clinic and receive controlled substances to control my pain, this Pain Medicine Agreement supersedes any other pain management agreement that I may have signed in the past.

I agree to the checked boxes above (Patient Signature) *

Clear

Name and contact information for the pharmacy

Patient Printed Name Physician Printed Name (or Appropriately Authorized Assistant)

Patient Signature Physician Signature (or Appropriately Authorized Assistant)

Clear

Patient Name

Patient Address

Patient Date of Birth

Medicare Number

Patient (or Legal Representative) Signature:

Printed Full Name

Date

Provider Signature

Provider Full Name

Date

Provider Retention Requirement: A copy of this signed contract will be retained by the provider for the entire opt-out period and made available to CMS upon request.

Patient Information

Address

Patient Name

Date of Birth

Contact Information

Cell Phone Number (for text):

Consent to Communicate via:

Text Message (SMS)

Risks of Communication via Text/Email

• Text and email are not guaranteed to be secure forms of communication.
• Your consent is voluntary, and you may revoke it at any time in writing.

5. Acknowledgment and Authorization

By signing below, I acknowledge that I have read and understand the risks of communicating via text and/or email. I authorize Dr. Howard Cohen, Dallas Mind + Body to contact me using the selected method(s) above for appointment reminders, treatment information, and other healthcare-related communications.

Patient Signature

Clear

Date

Note: This consent will remain in effect until revoked in writing by the patient.