If You Have Any Questions About the Appointment, Please Contact Our Office

You were sent this letter to sign because you are scheduled for an appointment at one of the offices of Northwest Neurological, PLLC (NWN) as noted on the attached card.

If you have any questions about the appointment, please contact our office.

By signing below, I acknowledge that:

c I authorize NWN to contact me in the following ways and I release NWN of any liability for release of information to the following contacts:

Home Telephone _________________________________

Cellular Telephone _________________________________

Work Telephone _________________________________

Email _________________________________

Mailing Address _________________________________

Fax _________________________________

My main preference for being contacted is ________________________

c NWN may contact anyone about my medical information if deemed a medical emergency.

c I hereby authorize the following person to speak on my behalf to the employees/associates of NWN, including but not limited to providers, reception, scheduling, medical assistants, billing, etc.

(Name)_____________________________ (Relationship)__________________ (Phone)______________

c NWN may also disclose information to the individual named above about alcohol abuse, substance abuse, HIV/AIDS or mental health if medically necessary.

c I have read the NWN Financial Agreement (attached)

c I have received and signed the form entitled “Authorization to Use and Disclosure Protected Health Information.”

c I have received the Notice of Privacy Practices of NWN

c The information provided above will remain in effect until I notify NWN in writing that a change has occurred and/or my thoughts are different than that noted above.

c I have been told that updated information may be available at our website (below)

Printed Name of Patient: _________________________________________ Date: _____________

Patient’s Signature*: ____________________________________________________________

*Or legally authorized Patient Representative

610 S Sherman St., #201, Spokane, WA 99202 Ph. (509) 458-7720 F. (509) 777-0432 www.nwn4me.com