PAIN MANAGEMENT AGREEMENT & INFORMED CONSENT

**Please check each statement if you have read and agree**

I authorize the doctor and my pharmacy to cooperate fully with any city, state, or federal law enforcement agency, including the States Board of Pharmacy and the Drug Enforcement Agency, in the investigation of any possible misuse, sale, or other diversion of my pain medicine. I authorize my doctor to provide a copy of this Agreement to my pharmacy. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to this.

Privacy Policy Consent and Acknowledgment

This consent will apply to all healthcare providers employed by and acting for the benefit of this office who conducts, plan and direct treatment and follow-up and be involved in treatment, directly or indirectly. In the course of providing services to you, this office will create, receive, and store health information that identifies you. It is often necessary to use and disclose information in order to treat you, to obtain payment for services and to conduct day to day health care operation. the Notice of Privacy Practices describes the uses and disclosures in detail. The use and disclosure of your health information may include care and services, follow-up care from another health professional, disclosure or your information for billing purposes or processing claims for obtaining payment or submission of claims to a third-party payer or insurer. You have the right to restrict the use or disclosure made for purposes of treatment or healthcare operations, but this office is not obligated to agree to these restrictions. If this office does agree, however, the restrictions are binding. You may revoke this consent in writing at any time, except to the extent that this office has taken action relying on this consent.

I have read this document and understand it. I consent to the use and disclosure of my personal health information for purposes of treatment, payment and healthcare operations. I have received a copy of the Notice of Privacy Practices from this office.

BY CLICKING SUBMIT, I AM GIVING MY FULL ELECTRONIC SIGNATURE AND AGREEMENT TO THE ABOVE STATED CONDITIONS.