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Scottsdale Clinic - New Patient Documents

First Name

Last Name

Date of Birth

Email

Phone Number

Office Policy

I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE OFFICE POLICY

I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE OFFICE POLICY

Please sign if you agree to the above OFFICE POLICY

Signature

Financial Agreement

I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE FINANCIAL AGREEMENT

I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE FINANCIAL AGREEMENT

Please sign if you agree to the above FINANCIAL AGREEMENT

Signature

HIPAA Policy

I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE HIPAA POLICY

I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE HIPAA POLICY

Please sign if you agree to the above HIPAA POLICY

Signature

Electronic Medical Release

Physician Name

Physician Phone Number

Imaging Facility Name

Imaging Facility Phone Number

Pharmacy Name

Pharmacy Phone Number

Other Location

Other Location Phone Number

RELEASE OF ELECTRONIC MEDICAL INFORMATION

I authorize Scottsdale Neurosurgical Specialists to release and receive electronic medical records concerning myself to and from any pharmacy, physician, hospital, imaging facility or any other agency involved in my care.

I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE RELEASE OF ELECTRONIC PRESCRIPTION AND MEDICAL INFORMATION. This will continue unless revoked by me in writing

I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE RELEASE OF ELECTRONIC PRESCRIPTION AND MEDICAL INFORMATION. This will continue unless revoked by me in writing

Please sign if you agree to the above Release of Electronic Medical Information

Signature

Photo Media Release

I grant, Scottsdale Neurosurgical Specialists, and his/her practice permission to take and use photographs and digital images of me for the purpose of:

RELEASE OF PHOTOGRAPHY OR DIGITAL IMAGES

I authorize Scottsdale Neurosurgical Specialists to release and receive electronic medical records concerning myself to and from any pharmacy, physician, hospital, imaging facility or any other agency involved in my care.

I understand that once my photograph(s) or digital image(s) have been released, Scottsdale Neurosurgical Specialists and his/her practice may no longer have control over them, and federal or state privacy laws may no longer protect the information that was released.

I may cancel this authorization to the extent allowed by law. If I do, I understand that the doctor or practice may have already used my photograph(s) or digital image(s) prior to me canceling this authorization, which would not prohibit any release done prior to the date of cancelation.

To cancel this agreement, I must write a letter to the doctor or practice advising of my wish to cancel my authorization to release photograph(s) or digital image(s) taken of me by this practice. I (or my authorized representative) must sign and date the letter.

Please sign if you agree to the above Photo Media Release

Signature