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Pain specialists of texas, Lp, 4927 lake ridge parkway, Suite 170, Grand
Prairie, TX 75052 CONSENT, ASSIGNMENT AND RELEASE: I AM PRESENTING MYSELF TO PAIN SPECIALISTS OF TEXAS (PSTX) FOR EVALUATION, DIAGNOSIS AND OR TREATMENT OF MY MEDICAL CONDITION. I GIVE MY CONSENT FOR MY PHYSICIAN(S) OR HIS DESIGNEES TO ORDER AND/OR PERFORM ALL EXAMS, TESTS, PROCEDURES, AND ANY OTHER CARE DEEMED NECESSARY OR ADVISABLE FOR THE EVALUATION, DIAGNOSIS AND TREATMENT OF MY MEDICAL CONDITION. THIS CONSENT IS VALID FOR EACH VISIT I MAKE TO PSTX UNLESS REVOKED BY ME IN WRITING. I UNDERSTAND THAT TEXAS LAW PROVIDES, AND I GIVE CONSENT, THAT I MAY BE TESTED FOR POSSIBLE EXPOSURE TO CERTAIN COMMUNICABLE DISEASES, INCLUDING BUT NOT LIMITED TO THE HUMAN IMMUNODEFICIENCY VIRUS (HIV), THE VIRUS ASSOCIATED WITH AIDS, HEPATITIS B AND C, AND SYPHILIS. SUCH TESTING WILL BE CONDUCTED PURSUANT TO APPLICABLE LAWS AND CAN INCLUDE BUT IS NOT LIMITED TO THE FOLLOWING SITUATIONS: 1) IF A HEALTH CARE WORKER IS EXPOSED TO MY BLOOD OR OTHER BODILY FLUID; 2) IF A MEDICAL OR SURGICAL PROCEDURE IS TO BE PERFORMED WHICH COULD EXPOSE HEALTH CARE WORKERS TO MY BLOOD OR BODILY FLUIDS; 3) TO SCREEN BLOOD, BLOOD PRODUCTS, ORGANS OR TISSUES TO DETERMINE SUITABILITY FOR DONATION; 4) IF I AM PREGNANT. IF I AM ELIGIBLE FOR HEALTH CARE BENEFITS UNDER ANY FEDERAL OR STATE PROGRAM, INCLUDING BUT NOT LIMITED TO MEDICARE OR MEDICAID, I CERTIFY THAT THE INFORMATION GIVEN BY ME IN APPLYING FOR PAYMENT UNDER SUCH PROGRAMS, INCLUDING TITLE XVIII AND XIX OF THE SOCIAL SECURITY ACT, IS CORRECT. I AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION OR INTERMEDIARIES OR CARRIERS INFORMATION NEEDED FOR ANY FEDERAL OR STATE PROGRAM RELATED CLAIMS. I REQUEST THAT PAYMENT OF AUTHORIZED BENEFITS BE MADE TO PAIN SPECIALISTS OF TEXAS ON MY BEHALF. I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL DEDUCTIBLE AND COINSURANCE AMOUNTS UNDER THESE PROGRAMS. I
HEREBY AUTHORIZE ALL INSURANCE BENEFITS OTHERWISE PAYABLE TO ME TO BE PAID
DIRECTLY TO I ALSO AUTHORIZE PAIN SPECIALISTS OF TEXAS TO RELEASE INFORMATION TO SECURE PAYMENTS ON MY BEHALF. I AUTHORIZE THE USE OF MY SIGNATURE TO BE USED ON ALL INSURANCE FORMS. I understand the Protected Health information (PHI) Policy for Pain Specialists of Texas is posted in the waiting area and on the website painspecialiststx.com. Copies are also provided by the office on request. SIGNATURE OF PATIENT______________________________________________ DATE__________________________________ SIGNATURE OF AUTHORIZED PARTY, IF NOT PATIENT_________________________________________ DATE________________
PAIN SPECIALISTS OF TEXAS INFORMATION RELEASE AUTHORIZATION It is the office policy of Pain Specialists of Texas not to release confidential and/or unauthorized information without the expressed consent of the patient. When returning telephone calls and the answering machine picks up, we cannot leave a detailed message if your name is not on the recorded message to identify the residence. I authorize Pain Specialists of Texas to contact me at the following numbers: Can leave detailed message Home Telephone Number ________________________ yes no Work Telephone Number _________________________ yes no Cell Telephone Number ____________________________ yes no Alternative Telephone Number _______________________ yes no If you would like other individuals to have access to your health/billing information, please list the names of the people below: NAME RELATIONSHIP LIMITATIONS ON RELEASING INFORMATION _______________________________________________________________________________________________________________
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