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Consent for Purposes of Treatment, Payment and Health care Operations

I consent to the use and disclosure of my protected health information by Pain Management Technologies, Inc. (PMT Medical) for the purpose of providing supplies to me, obtaining payment for my health care bills or to conduct the health care operations of PMT Medical.

My Protected health information means health information, including my demographic information collected from me and created or received by my physician, another health care provider, health plan, my employer or a health care clearinghouse. This protected health care information relates to my past, present or future physical health or condition and identifies me, or there is reasonable basis to believe the information may identify me.

I understand that my receiving supplies from PMT Medical may be conditioned upon my consent as evidence by my signature on this document.

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out services, payments, or healthcare operations of the company.

PMT Medical is not required to agree to the restrictions that I may request. However, if PMT Medical agrees to restrictions that I request, the restrictions are binding on PMT Medical and PMT Medical employees.

I have the right to revoke this consent, in writing, at any time, except that PMT Medical has taken action in reliance on this consent.

I understand I have a right to review PMT Medical Notice of Privacy Practices prior to signing this document. The PMT Medical Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosure of my protected health that will occur in my receiving services, payment of my bills or in the performance of health care operations of PMT Medical. Notice of Privacy Practices also describes my rights and PMT Medical duties with respect to my protected health information.

PMT Medical reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail.

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Signature of Patient or Personal Representative


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Name of Patient or Personal Representative


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Date

Print out (CTRL P TO PRINT) and mail or fax form to

Pain Managment Technologies, Inc.
1340 Home Avenue
Building A
Akron, OH 44310

FAX: 888-304-5454