NEUROSPINE SOLUTIONS
New Patient Packet

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Telephone Number/Medical Information Release

This form is required under HIPPA privacy regulations to authorize where/how we may contact you and to whom we can release information about you.

I the undersigned, give my permission to Neuro Spine Solutions, P.C. to contact me at the following location by circling the answer that applies.

  1. yes | no ----- Home Telephone Number: _____________________________________________
  2. yes | no ----- Cell Phone Number: __________________________________________________
  3. yes | no ----- Work Telephone Number: ______________________________________________
  4. yes | no ----- O.K. to leave a message on answering machine/voice mail? *

* All four of the above questions must be answered. If you do not have a cell phone, answering machine or work number circle the "no" box.

If for some reason Neuro Spine Solutions, P.C. needs to relay my protected medical information (i.e.:procedures, test results, lab results, billing issues, etc.)you can either leave a message with or discuss the information with the following individuals.

  1. Name: ___________________________________________ Telephone: ______________________________
  2. Name: ___________________________________________ Telephone: ______________________________
  3. Name: ___________________________________________ Telephone: ______________________________
  4. Name: ___________________________________________ Telephone: ______________________________

Parent or Guardian (Print): _____________________________________________________

Signature: __________________________________________________ Date: ______________________________