THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
This Privacy Notice is being provided to you as a requirement of a federal law, the Health Insurance Portability and Accountability Act (HIPAA). This Privacy Notice describes how we may use and disclose your protected health information to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your right to access and control your protected health information. Your “protected health information means any written or oral information about you, including demographic data that can be used to identify you created or received by your health care provider, which relates to your past, present, or future physical or mental health or condition.
Uses and Disclosures of Protected Health Information for Treatment, Payment, and Health Care Operations.
We may use your protected health information for the purposes of providing treatment, obtaining payment for treatment and conduction health care operations. Your protected health information may be used or disclosed only for these purposes unless we have obtained your authorization or the use or disclosure is permitted or required by the HIPAA regulations or other law. Disclosures of your protected health information for the purposes described in this Privacy Notice may be made in writing, orally, or by electronic means.
1. Treatment. We will use and disclose your protected healthcare information to provide, coordinate, or manage your health care and related services, including coordination and management with third parties for treatment purposes. Here are some examples of how we may use or disclose your protected health
information for treatment
a. We may disclose your protected health information to a laboratory to order tests.
b. We may disclose your protected health information to other physicians who may be treating you or
consulting with us regarding your care
c. We may disclose your protected health information to those who may be involved in your care after you leave here, such as family members or your personal representative
2. Payment we will use your protected health information to obtain payment for the services we provide to you. We may also disclose your protected health information to another provider involved in your care for their payment activities. Here are some examples of how we may use or disclose your protected health information for payment:
a. We may communicate with your health insurance company to get approval for the services we render, to
verify your health insurance coverage, to verify that particular services are covered under your insurance
plan, and to demonstrate medical necessity.
b. We may disclose your protected health information to anesthesia care providers involved in your care so they can obtain payment for their services.
3. Health Care Operations. We may use and disclose your protected health information to facilitate our own health care and to provide quality care to all of our patients. Health care operations include such activities as: quality assessment and improvement; employee review activities, conduction or arranging for medical review, legal services, and auditing functions, including fraud and abuse detection and compliance reviews, business planning and development; and business management and general administrative activities. In certain situations, we may also disclose your protected health information to another provider or health plan for their health care operations. Here are some examples of how we may use or disclose your protected health information for health care operations:
a. We may use your protected health information to review our treatment and services and to evaluate the performance of our staff in caring for you.
b. We may combine protected health information about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective
We may also disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes,
d. We may also use or disclose your protected health information in the course of maintenance and
management of our electronic health information systems.
Uses and Disclosures of Protected Health Information permitted without Authorization or Opportunity for the Individual to Object.
The federal privacy rules allow us to use or disclose your protected health information without your authorization and without your having the opportunity to object to such use or disclosure in certain circumstances, including:
1. When Required By Law. We will disclose your protected health information when we are required to do so by federal, state, or local law.
2. For Public Health Reasons. We may disclose your protected health information as permitted or required by law for the following public health reasons:
a. For the prevention, control, or reporting of disease, injury or disability:
b. For the reporting of vital events such as birth or death
c. For public health surveillance, investigations, or interventions;
d. For purposes related to the quality, safety, or effectiveness of FDA-regulated products or activities, including:
i. Collection and reporting of adverse events, product defects or problems, or biological product
ii. Tracking of FDA-regulated products.
iii. Product recalls, repairs, or look back.
iv. Post-marketing surveillance.
e.To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease or condition;
f. Under certain limited circumstances, to report to an employer information about an individual who is a member of the employer’s work force
2. To Report Abuse, Neglect, or Domestic Violence. We may notify government authorities if we believe a patient is a victim of abuse, neglect, or domestic violence. We will make this disclosure only when specifically authorized or required by law, or when the patient agrees to the disclosure.
3. For Health Oversight Activities. We may disclose your protected health information to a health oversight agency for oversight activities authorized by law, including audits, civil, administrative, or criminal investigations; inspections, licensure or disciplinary actions, civil, administrative, or criminal proceedings or actions; or other activities necessary for appropriate oversight.
4. For Judicial or Administrative Proceedings. We may disclose your protected health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order. We may disclose your protected health information in response to a subpoena, discovery request, or other lawful process that is not accompanied by an order of a court or administrative tribunal if we have received satisfactory assurances that you have been notified of the request or that an effort has been made to secure a protective order.
5. For Law Enforcement Purposes. We may disclose your protected health information to a law enforcement official for law enforcement purposes, including
a. Wound or physical injury reporting, as required by law.
b. In compliance with, and as limited by the relevant requirements of a court order or court-ordered warrant, a
subpoena, summons, or similar process.
c Identification or location of a suspect, fugitive, material witness, or missing person.
d. Under certain limited circumstances when you are the victim of a crime.
e Alerting law enforcement of the death of an individual where there is suspicion that the death may have
resulted from criminal conduct.
f. Reporting criminal conduct that occurred on the premises of the provider.
g. In an emergency to report a crime.
6. To Coroners, Medical Examiners, and Funeral Directors. We may disclosed protected health information to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law. We may disclose protected health information to funeral directors, consistent with applicable law, as necessary to carry out their duties with respect to the decedent. In some cases such disclosures may occur prior to, and in reasonable anticipation of the individual’s death.
7. For Organ or Tissue Donation. We may use or disclose protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of cadaveric organs, eyes, or tissue for the purpose of facilitating donation and transplant.
8. For Research Purposes. We may use or disclose your protected health information for research purposes when an institutional review board that has reviewed the research proposal and protocols to safeguard the privacy of your protected health information has approved such use or disclosure.
9. To Avert a Serious Threat to Health or Safety. We may, consistent with applicable law and standards of ethical conduct, use or disclose your protected health information if we believe in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health and safety or that of the public.
11. For Specialized Government Functions. We may use or disclose your protected health information, as authorized or required by law, to facilitate specified government functions related to military and veterans activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations; correctional institutions and other law enforcement custodial situations.
12. For Workers’ Compensation. We may use and disclose your protected health information, as necessary, to comply with workers’ compensation laws or similar programs.
Uses and Disclosures of Protected Health Information Permitted without Authorization but with an opportunity for the Individual to Object
We may use your protected health information to maintain a directory of patients in our facility. The information included in the directory will be limited to your name, your location in our facility, and your condition described in general terms. We may disclose your protected health information to a friend or family member who is involved in your medical care or payment for care. In addition, if applicable, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. You may object to these disclosures. If you do not object to these disclosures, or we determine in the exercise of our professional judgment that it is in your best interest for us to disclose information that is directly relevant to the person’s involvement with your care, we may disclose your protected health information.
Uses and Disclosures of Protected Health Information which You Authorize.
Other than the uses and disclosures described above, we will not use or disclose your protected health information without your written authorization. We require your written authorization in order to use or disclose your protected health information for:
•marketing, except if the communication is in the form of a face-to-face communication made by us to you, or a promotional gift of nominal value that we provide to you, and
•any sale of your protected health information.
Authorizations are for specific uses of your protected health information, and once you give us authorization, any
disclosures we make will be limited to those consistent with the terms of the authorization. You may revoke your
authorization, by submitting a revocation in writing, at any time, except to the extent that we have already taken action in reliance upon your authorization
Your Rights Regarding Your Protected Health Information.
You have the following rights regarding your protected health information:
1. The Right to Request Restriction of Uses and Disclosures. You have the right to request that we not use or disclose certain parts of your protected health information for the purposes of treatment, payment, or healthcare operations. You also have the right to request that we do not disclose your protected health information to friends or family members who may be involved in your care, or for notification purposes as described earlier in this notice. Your request must be made in writing and must state the specific restriction requested and the individuals to whom the restriction applies.
2. We must agree to your request to restrict disclosure of your protected health information to a health plan if:
a. the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and
b. the protected health information pertains solely to a health care item or service for which you or someone else has paid out-of-pocket in full.
3. Otherwise, we are not required to agree to a restriction you may request.
4. We will notify you if we do not agree to your restriction request. If we do agree to the restriction request, we will not use or disclose your protected health information in violation of the agreed upon restriction, unless necessary for the provision of emergency treatment.
5. We may terminate our agreement to a restriction if you agree to the termination in writing, if you agree to the termination orally and the oral agreement is documented, or if we notify you of termination of the agreement and the termination applies only to protected health information created or received by us after you receive the notice of termination of the restriction.
6. Request for restrictions must be made in writing to the Privacy Officer
7. The Right to Request Confidential Communications. You have the right to request that you receive communications of protected health information from us by alternative means or at alternative locations. We must accommodate any reasonable request of this nature. We may condition the provision or accommodation by requesting information from you describing how payment will be handled, or by requesting specification of an alternative address or alternative form of contact
8. Requests for confidential communications must be made in writing to the Privacy Officer
9. The Right to Inspect and Copy Protected Health Information. You have the right to inspect and obtain a copy of your protected health information that is maintained in a designated record set for as long as we maintain the protected health information. The designated record set is a collection of records maintained by us, which contains medical and billing information used in the course of your care, and any other information used to make decisions about you.
10. By law, you do not have a right to access psychotherapy notes; information compiled in reasonable anticipation of, or for use in a civil, criminal, or administrative proceeding, and protected health information which is subject to a law which prohibits access to protected health information. Depending on the circumstance of your request, you may have the right to have a decision to deny access reviewed.
11. We may deny your request to inspect or copy your protected health information if in our professional judgment, we determine that the access requested is likely to endanger you or another person, or is likely to cause substantial harm to another person referenced within the protected health information. You have a right to request a review of a denial of access
12. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing, or other costs incurred by us as a result of complying with your request.
13. Requests for access to your protected health information must be made in writing to the Privacy Officer.
14. The Right to Amend Protected Health Information. You have the right to request that we amend your protected health information in a designated record set for as long as we maintain that information. In certain cases we may deny your request. If we deny your request you will be notified in writing, and you will have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement of disagreement and if we do so we will provide acopy of our rebuttal to you.
15. Requests for amendment of protected health information must made in writing to the Privacy Officer, and must include a reason to support the requested amendments.
16. The Right to Receive an Accounting of Disclosures of Protected Health Information. You have the right to request an accounting of disclosures of your protected health information made by us. This right applies to disclosures made by us except for disclosures: to carry out treatment, payment, or health care operations as described in this Notice or incidental to such use; to you or your personal representatives, pursuant to your authorization for our directory, or other notification purposes, or to persons involved in your care, or for certain other disclosures we are permitted to make without your authorization.
17. Requests for disclosure of accounting must specify a time period sought for the accounting, with the maximum time period being six years prior to the date of the request. We are not required to provide accounting for disclosures made before April 14, 2003. We will provide the first disclosure accounting you request during any 12-month period without charge. Subsequent disclosure accounting request will be subject to a reasonable cost-based fee.
18. The Right to obtain a Paper Copy of this Notice. Upon request, we will provide a paper copy of this notice.
Your Rights Regarding Your Protected Health Information.
We are required by law to maintain the privacy of your health information and to provide you with this Privacy Notice of our legal duties and privacy practices with respect to protected health information. We are required by law to notify you if a breach of your unsecured protected health information occurs. We are required to abide by the terms of the Notice currently in effect. We reserve the right to change the terms of this Notice and to make any new provisions effective for all protected health information that we maintain. If we change the Notice, we will provide a copy of the revised notice through in-person contact.
You have the right to express complaints to us and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. If you wish to complain to us, please do so in writing, and direct your complaint to the Privacy Officer. You will not be penalized for filing a complaint.
For further information about this Notice, privacy issues, or if you believe that your privacy rights have been violated please contact:
Chief Clinical Officer/Compliance Officer
Joint Implant Surgeons, Inc.
7277 Smith’s Mill Road
New Albany, OH 43054
The CCO may be contacted by telephone at 614-221-6331 ext. 326
Effective Date: This Notice is effective April 21, 2013.
As you prepare for your upcoming surgery, we want to provide you with information regarding the association between orthopedic manufacturers and Joint Implant Surgeons, Inc. doing business as JIS Orthopedics, and its principals, Dr. Lombardi, Dr. Berend, Dr. Hurst, Dr. Morris, Dr. Reed, Dr. Snook, Dr. Crawford, and Dr. Byrd. It is important to our practice that you are aware of these relationships with implant manufacturers, that our office puts the interests of patients first, and that we are available to answer any questions that you may have.
Since its inception in the 1970’s, Joint Implant Surgeons, Inc. and its physicians have been dedicated to providing patients with excellent orthopedic care. Our practice philosophy has always involved exemplary patient care combined with research and education. This has afforded us the opportunity to evaluate and treat thousands of patients on an annual basis. It is this type of practice pattern that has kept us at the forefront of technology. It has afforded us great insight into the implant requirements of our patients, as well as patients throughout the world. We have refined surgical technique and have designed instruments that facilitate the operative intervention. This intellectual property has been shared with and developed in conjunction with orthopedic manufacturing. We have provided and continue to provide consulting services with orthopedic manufacturing. We perform numerous instructional lectures on implants and surgical techniques for physicians and medical personnel. We are a host site to a number of national and international physicians who come to learn about our techniques.
Currently, Dr. Lombardi and Dr. Berend are paid consultants to Zimmer Biomet. Dr. Lombardi, Dr. Berend, and Dr. Hurst receive royalties from Zimmer Biomet. Dr. Lombardi receives royalties from Innomed. Dr. Lombardi and Dr. Berend have minority investment interests in Parvizi Surgical Innovation, VuMedi, and Elute Inc. Dr. Berend is a paid consultant to Engage Surgical. Dr. Lombardi, Dr. Berend, Dr. Hurst, and Dr. Morris have minority investment interests in SPR Therapeutics, Joint Development Corporation, and Prescribe Fit. Dr. Hurst and Dr. Morris are paid consultants to and receive royalties from Total Joint Orthopedics. Dr. Snook has minority financial interests in Midwest Neurology, Midwest R&D, and Prescribe Fit. Dr. Crawford is a paid consultant to DePuy, a Johnson & Johnson Company and Medacta. JIS Research Institute receives research support from Zimmer Biomet, Total Joint Orthopedics, Firstkind, and Parvizi Surgical Innovation Research Institute. Drs. Lombardi, Berend, Hurst, Morris, Snook, Crawford, and Byrd use products from these companies in the care of their patients, but also use similar products from other implant manufacturers. Our selection of prosthetic requirements for patients is based on patient specific need and not on a specific implant in which we have a vested interest since we receive no financial remuneration on any implants we use personally, or any implants used at facilities at which we operate.
We would also like to disclose our relationship with White Fence Surgical Suites, Southeast Ohio Surgical Suites. The physicians of Joint Implant Surgeons, Inc. have a financial interest in White Fence Surgical Suites and Southeast Ohio Surgical Suites. We do not require our patients to use White Fence Surgical Suites or Southeast Ohio Surgical Suites, and every patient has the option to use an alternative health care facility.
We are members of the American Academy of Orthopaedic Surgeons (AAOS), which holds its members to extremely high ethical standards to ensure that even the appearance of a conflict of interest does not jeopardize the trust that the patients place in their physicians. AAOS has adopted Standards of Professionalism that require orthopedic surgeon members to identify and disclose potential conflicts of interest to their patients, the public, and colleagues. These standards also clearly articulate how and under what circumstances AAOS members may work with and be compensated by industry, as well as the penalties for failure to comply.
You can learn more about these Standards of Professionalism at the AAOS website: https://www.aaos.org/About/Statements/Ethics_and_Professionalism/
‘Thank you for choosing Joint Implant Surgeons, inc. as your healthcare provider. We are honored by your choice and are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our patent financial policies.
The patient (or patient’s guardian, if a minor) is ultimately responsible for the payment for his/her treatment and care. Your insurance is a contract between you and the insurance company. We are not a party to that contract. It is very important that you understand the provisions of your policy. We cannot guarantee payment of all claims. If your insurance company pays only a portion of the bill or rejects our claim, any contact or explanation should be made to you their policy holder. Reduction or rejection of your claim by your insurance does not relieve you of your financial obligation.
1. You are required to provide us with the most correct and updated information about your insurance and will be your responsibility for any charges incurred if the information provided is not correct or updated. Your insurance card and proof of identification is required to be shown at each visit. IF you are covered by Medicaid you are required to bring your current month’s card with you to all visits.
2. Patients are responsible for the payment of co-pays, coinsurance, deductibles and all other procedures or treatment not covered by their insurance plan. Payment is dues at the time of service. We will ask for payment on any balances after insurance payments from previous services. We accept cash, check, and most major credit cards at our office. Failure to pay co-payment will result in a $20.00 processing fee which will be applied to your account.
3. If we do not participate with your insurance plan, you will be expected to make payment in full at time service is rendered.
BWC Patients: It is your responsibility to make sure you have authorizations from your managed care organization (MCO) for each visit. Failure to have authorization will result in a denial of payment from you MCO, leaving you responsible for payment.
No Insurance/Motor Vehicle Accidents: If you have no billable health insurance or were involved in an accident, you will be required to pay in full at time of service.
Medicare: We are participating providers with Medicare and will bill Medicare for all your covered charges. If you have supplemental insurance, we will also bill that for you. If payment is not received from your supplemental insurance within 45 days of being submitted, we will bill you for the balance due. If you do not have supplemental insurance, your portion (20% of the amount allowed by Medicare) will be collected at the time of service. Each year you will be expected to pay the allowed amount of your charges until your Medicare deductible is met.
HMO-PPO Patients: If we participate with your plan, we will bill your insurance for you. Your co-payment will be collected at the time of service- NO EXCEPTIONS. If your plan requires you to have an authorization/referral to see one of our physicians, it is your responsibility to have the referral with you and on file in our office at your appointments. If we do not participate in your plan, we will verify your out-of-network benefits, file your charges and will expect payment on your portion of the charges at the time of service.
Amniotic Tissue Injections: Please keep in mind that amniotic injections are shipped overnight on a patient specific basis and have a one day shelf life. A 50% upfront payment is due upon scheduling and is non refundable. The remaining balance is due on the day of your appointment.
Self Pay Patients: Patients with no insurance will be expected to pay at the time of service. If you will not be able to pay in full, you will need to contact our business office prior to seeing the physician to discuss possible payment arrangements.
1. Insurance regulations suggest that we inform you in advance if we believe certain services/supplies, such as durable medical equipment may not be covered by your insurance carrier. Although this implies that such services and/or supplies may not be medically necessary, in our professional judgment these services/supplies are needed in order to render the highest quality of care to you
2. You agree, in order for us to provide services for you and your account and/or to collect any amounts you may owe, we may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or e-mails, using any e-mail address you provide us. Methods of contact may include using pre-recorded/ artificial voice messages and/or use of an automatic dialing device, as applicable.
3.Patients may incur and are responsible for payment of additional charges at the discretion of Joint Implant Surgeons, Inc. These charges may include, but are not limited to Charges for Returned Checks; Missed Appointments Not Cancelled within 24 hours, Extensive Consultations, Copying and Distribution of Medical Records, Forms Completions and all costs association with collecting of account balance.
Thomas H Mallory, MD, FACS
Amy Glenn, APRN-CNP
Jennifer J. Perkins, FNP-BC
Kurt A Berlekamp, PA-C
Matthew C. Blouir, PA-C
Michael A. Malfatto, PA-C
Kyle W Storc, PA-C
Michael C. Thomas, PA-C
.ADOLPH V. LOMBARDI, JR. MD, FACS | KEITH R. BEREND, MD
JASON M. HURST, MD | MICHAEL J. MORRIS, MD | DEREK L. SNOOK, MD
DAVID A. CRAWFORD, MD | ZACKARY O. BYRD, MD | A. J. JULKA, MD
CONTROLLED SUBSTANCES AGREEMENT
This Controlled Substance Medication Agreement is a tool to allow the physician and patient to work together in good faith, and for you, the patient, to understand the importance of these medications. A “controlled substance medication” is a drug or chemical that is regulated by the government because of its
illegality for sale or use not prescribed by a physician, In prescribing a controlled substance medication, we
must partner with our patients to create the best treatment plan for your improvement and management of pain, This requires cooperation, trust, and mutual respect. you cannot agree to the following terms, we will be unable to prescribe controlled pain medication, Failure to follow all terms will result in discontinuation of the pain medication and/or dismissal from our practice.
1. I understand that there ie a risk of psychological and/or physical dependence and addiction
with chronic use of controlled substances
2. I understand that Joint Implant Surgeons may prescribe a controlled substance medication as part of my treatment plan for post operative pain management. The medication will not be prescribed for long term pain control, and will cease at 12 weeks post op.
3. I will take the mediation exactly as prescribed and | will not change the medication dosage and/or
frequency without the approval of my surgeon/physician managing pain
4. I will keep regularly scheduled appointments with my surgeon, There may be times when your
medications will ned a refill between office visits. If that occurs, please call our staff at least 1 to 2 days before your medication runs out, Refill requests will ONLY be taken on Monday-Thursday from 8 a.m. to 4 p.m. and Friday from 8 a.m. to 12 p.m. Any request for controlled substance pain medications after 12pm on Fridays WILL NOT be considered for refill until Monday morning at 8am. Your physician or an on-call physician may not refill pain medication after hours or on weekends.
5. The controlled substance pain medication prescribed is being given in order to control pain, improve function, and complete post-operative exercises. I there are any changes to my activity level or physical condition, the treatment may be changed. I am responsible for notifying my surgeon and Joint Implant Surgeons of such changes.
6. I will be ready to taper or discontinue the controlled substance pain medication as my condition
improves. Your surgeon will not prescribe narcotics pre-operatively or past the 12 week post-operative date. Your surgeon may recommend further workup if you still require narcotics past 12 weeks. If work-up is negative, you will be referred to a pain management specialist for management of your pain medications.
7. I would also be amenable to seek psychiatric treatment, psychotherapy, and/or psychological treatment if my provider deems necessary
8. I am not to accept or seek controlled substance pain medication from any other physician or healthcare
provider outside of this practice while Joint Implant Surgeons is prescribing pain medication. If you already have a pain management physician they will need to be Included in your post-operative pain
management and will be the party responsible for managing your pain above and beyond normal post-
9. If I have another condition that requires the prescription of a controlled substance (narcotics,
tranquilizers, benzodiazepines, barbiturates, or stimulants),I will be asked to coordinate all
medications with that prescribing physician, including any pain medication for my orthopedic
10. It is required that I use a single pharmacy for all prescriptions. I may use a chain of pharmacies with different branches, as the prescription information is available at all branches. This is required to make certain that my medications are known by a pharmacist able to evaluate any concerns about interactions of medications.
11. I agree that I will use my medicine a a rate no greater that the prescribed rate and that use of my medicine at a greater rate will result in my being without medication for a period of time.
12. I understand that lost, stolen, or misplaced prescriptions or pills WILL NOT be replaced. All patients are required to act responsibly with their medications. This medication is prescribed for you and only your specific pain needs. To allow others to use your pain medication is illegal and dangerous. This type of behavior will not be tolerated by your surgeon or our practice.
13. I agree that | will not use any other illegal/recreational drug or alcohol while receiving pain mediation from this practice. Use of illegal/recreational drugs and alcohol, especially while also taking pain medication, is extremely dangerous and potentially lethal.
14, I will not use narcotic medication while driving or operating machinery as it poses a threat to my life/ limbs as wall as the safety of others.
15. I authorize the provider and my pharmacy to cooperate fully with any city state or federal aw
enforcement agency, including this state’s Board of Pharmacy, in the investigation of any possible
misuse, sale, or other diversion of my pain medication. I authorize my provider to provide a copy of
this Agreement to my pharmacy, primary care provider and local emergency room. I agree to waive
any applicable privilege or right of privacy or confidentiality with respect to these authorizations.
16, I agree to follow these guidelines that have been fly explained to me. All of my questions and
concerns regarding treatment have been adequately answered.