Downloadable Forms All of the following forms are available to read and/or print using Adobe Reader. If you do not have the Adobe Reader installed on your computer it can be obtained at no cost by clicking on the link at the bottom of the page. New Patient Packet - Contains Checklist, Pain Questionnaire, Past Medical History, Map, Medical Records Release, Patient Authorization for Disclosure of Health Information, & Financial Policy. Please make sure this is completed prior to your first visit. Physician Referral Form - Physicians who are referring patients to Cumberland Pain Associates, PLC may use this form to communicate the purpose of the referral. Contains a checklist of all procedures and evaluations performed at our clinic. Medical Records Release - Please sign this release in order for us to have your records forwarded to us. Outgoing Medical Records Release - Please complete this release in order for your records to be forwarded to the physician of your choice. Please note: Patients will be charged a processing fee of $20.00 to have their records forwarded. Authorization for Use of Healthcare Information - Please complete this form so that we may have permission to disclose your health information to those whom you have authorized. (For example: your spouse, children, parents) Notice of Privacy Practices - This notice details your rights as a patient and our responsibilities as providers when it comes to protecting your privacy and healthcare information.
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