Advanced Spine, Sports & Rehab Practice Requirements

The Practice:

1. Is required by federal law to maintain the privacy of your PHI (Personal Health Information) and to provide you with the Privacy Notice detailing the Practice’s duties and privacy practices with respect to your PHI.
2. Under the Privacy Rule, may be required by State Law to grant greater access or provided for under federal law.
3. Is required to abide by the terms of this Privacy Notice.
4. Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for your entire PHI it maintains.
5. Will distribute any revised Privacy Notice to you prior to implantation.
6. Will not retaliate again you for filing a complaint.

Effective Date- This notice is in effect as of 4/15/2003

Patient Acknowledgement:

By subscribing my name below, I acknowledge receipt of a copy of this Notice, and my understanding and my agreement to its terms.

______________________________________________________________________

Patient Signature                                                                                            Date

X-Ray Questionnaire: For Women Only

Our consultation and examination may indicate that x-rays are necessary to accurately diagnose and analyze your spinal condition.  Should x-rays be necessary, we would like to confirm that you are NOT pregnant at this time.

1.  There is a possibility that I may be pregnant at this time:  Y/N

2.  Yes, I am definitely pregnant: Y/N

3.  No, I am definitely NOT pregnant:  Y/N

4.  I request that x-ray films not be taken because:______________________________

Date of last menstrual cycle: _______________________

Patient Signature________________________________________________________________