If you are human, leave this field blank. Consent to Treatment and Administrative Authorizations
1. Authorization for Treatment and Diagnostic Procedures I voluntarily authorize, request and consent to outpatient care services, including procedures, examinations, and medical treatment as ordered by my physicians, his/her assistants, or other health care provides. I understand that, except in emergency situations, this consent does not include surgical procedures or other procedures or treatment that may require separate consent. I acknowledge that the practice of medicine is not an exact science and that no guarantees have been made as to the results of any procedures, treatments or examinations.
2. Release of Information (Including Medical Record Information) I authorize the Pennsylvania Pain & Spine Institute to furnish health, demographic, and other information from my medical records to my insurance company, third-party payers, case utilization, and managed care review organizations, which may be necessary in order for Pennsylvania Pain & Spine Institute to receive payment or obtain authorization for my care. I further authorize health, demographic, and other information from my medical record to be released to any health care provider or institution providing health care to me. Consent is also given for release of information to Pennsylvania Pain & Spine Institute by any insurer and all other agencies, institutions, or from whom I have received medical services. This authorization does not apply to information specifically protected by state or federal laws or regulations.
3. Assignment of Insurance Benefits to Pennsylvania Pain & Spine Institute I authorize payment of health care benefits directly to Pennsylvania Pain & Spine institute. In making this assignment, I understand and agree that I may be financially responsible to Pennsylvania Pain & Spine Institute for charges not pain under my insurance policy(ies). I permit a copy of this authorization to be used in place of the original. I authorize payment of authorized Medicare or other payor benefits to be made to me or on my behalf, to the physician or supplier for any services provided to me by the authorized physician or supplier. I authorize any holder of medical information about me to release to the Center for Medicare and Medicade Services and its agents and information needed to determine these benefits or the benefits payable for related services. I hereby certify that I have read and fully understand the above consent. I have sufficient opportunity to ask whatever questions I might have and they have been answered to my satisfaction. I voluntarily and freely consent to the above and accept its term.
Date REVIEW OF SYSTEMS
For new patients, established patients who may be having a new problem, or our patients who we haven?t seen for a while, we need to update our records as to your general medical health. In each area, if you are not having any difficulties, please select ?No Problems?. If you are experiencing any of the symptoms listing,
PLEASE CHECK ALL BOXES THAT APPLY, or explain any that may not be listed. If you have any questions about this, please ask one of the technicians, or your doctor. Const. (Health in General)
unexplained weight gain or weight loss
prior diagnosis of cancer
Other GI (Stomach & Intestines)
intolerance to certain foods
unexplained change in bowel habits
Other Endocrinologic (Glands)
Intolerance to heat or cold