CFIPain Patient Forms HIPPA - Notice of Privacy v2 I. Acknowledgement of Practice's HIPAA Privacy Notice:By subscribing my name below, I acknowledge that Elyaman medical Service PA, DBA Central Florida Interventional Pain has provided a copy of the HIPAA Privacy Notice, and that I have read (or had the opportunity to read if so chose) and understand my rights and ask questions regarding my rights and receive answers to my satisfaction and agree to its terms.II. Designation of Caregivers as my Personal Representative:I give permission for the following person(s) to pick up prescriptions and or any of my personal health information, to include super sensitive information on my behalf. I understand that no prescriptions will be released other than to the person(s) listed below. *Please Note - Person(s) listed below will be required to present driver's license or other state/federally issued photo ID when picking up prescriptions, billing information, and/or any personal health information.Caregiver 1 Name First Last Caregiver 1 PhoneCaregiver 1 Relationship Caregiver 2 Name First Last Caregiver 2 PhoneCaregiver 2 Relationship III. Request to Receive Confidential Communications by Alternative Means:As provided by Privacy Rule Section 164.522(b), I hereby request that the Practice make all communications to me by the alternative means that I have listed below.Home / Cell Telephone Number:Phone Message Choice OK to leave message with detailed information Leave message with call back numbers only Work Telephone Number:Work Phone Message Choice OK to leave message with detailed information Leave message with call back numbers only FAX Communication Number:FAX Message Choice OK to fax to the number listed above Written Communication Address: Mail (Physical) Address Email Address Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Enter Email Confirm Email Signed by:(Required) Patient Legally Authorized Representative of Patient Signature of Patient or Legal Representative(Required)Date Signed(Required) MM slash DD slash YYYY