Acknowledgement of Notice of Privacy Practices

I have received a copy of the Notice of Privacy Practices of Athens Spine Center on the date indicated below. I understand that if any changes are made to this Notice of Privacy Practices, a revised copy of the Notice will be posted in the offices of Athens Spine Center. I also understand that if I wish to receive additional copies of this Notice of Privacy Practices in the future or if I have any questions with regard to this Notice of Privacy Practices, I may contact Athens Spine Center at 706-425-2400.

Patient Name*

First Name

Last Name

Date of Birth*

Signature of Patient*

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Date*

Witness*

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Consent for Disclosure To Family Member and/or Personal Representative

I have agreed to let certain individuals participate in discussions and decisions related to my medical care. Therefore, I hereby give my permission for Athens Spine Center PC, doctors and medical staff to disclose my personal medical information to the following individuals:

Name*

First Name

Last Name

Relationship*

Name

First Name

Last Name

Relationship

Name

First Name

Last Name

Relationship

CONDITIONS FOR DISCLOSURE:

The practice may disclose my personal health information to the individual(s) above only in my presence. The practice may disclose my medical information to the individuals above in discussions in my presence and when I am not physically present, including disclosures by telephone, facsimile, e-mail or regular mail. Other Conditions of Disclosure:

If other, please explain

I understand that this consent is in effect until revoked by me by written notice to the practice.

Patient Name*

First Name

Last Name

Date of Birth*

Signature

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Date*

Witness Signature*

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Witness Name*

First Name

Last Name

Title/Position*

Date*