Pain Consultants of the Rockies, PC
and Pain Treatment Center of Wyoming, LLC

903A South Greeley Highway, Cheyenne, WY  82007
307-633-8100  Fax: 307-633-8108 

NOTICE OF PRIVACY PRACTICES & ACKNOWLEDGEMENT

This is a description of how your health information may be used and disclosed and how you can gain access to this information.

PLEASE REVIEW THIS CAREFULLY

 Each time you visit our office or treatment center, a record of this visit is made.  This record is referred to as your “medical record”.  Your medical record contains your health information including symptoms, examination findings, lab or x-ray results, diagnoses, treatment and plans for your care.

Our facilities have policies in place requiring our staff to maintain the privacy of your health information.  These policies may be changed, but our staff must stay abreast of these changes and continue to abide by them. 

USES AND DISCLOSURES

Your health information will be disclosed:

• To healthcare professionals providing, coordinating and/or managing your health care or related services and

• To insurance agencies or third party payers for the purpose of reimbursement for services rendered.

Disclosure of your health information may be made:

• When required by federal, state or local law and

• In matters of public health & safety.

DISCLOSURE OF YOUR HEALTH INFORMATION FOR ANY OTHER PURPOSE WILL REQUIRE YOUR WRITTEN, SIGNED AUTHORIZATION.

YOUR RIGHTS

You have the right to:

• Request a restriction on some disclosures of your health information.  However, if our facilities are unable to agree to said restriction, you will be notified of the reason.
• Inspect and obtain a copy of your medical record unless restricted by federal law.  There may be a copying fee attached.
• Request amendment of your medical record.
   

 ACKNOWLEDGEMENT

I hereby acknowledge receipt of my copy of this Notice of Privacy Practices from Pain Consultants of the Rockies, PC and/or the Pain Treatment Center of Wyoming, LLC.

___________________________________                       _____________________
Patient/Agent Signature                                                         Date

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Copyright © 2004 Pain Consultants of the Rockies, PC and Pain Treatment Center of Wyoming, LLC.