Patient Health History - Intake Form Page 7
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8Pain Management Associates
305 West Grand Avenue Suite 500
Montvale, NJ 07645
Tel: 201-326-4777 ● Fax: 201-391-1196
Acknowledgement of Patient Rights and Privacy Practices
By signing below, I acknowledge that I have been provided a copy of this Notice of Privacy Practices
and have therefore been advised of how health information about me may be used and disclosed
by our practice listed at the beginning of this notice, and how I may obtain access to and control this
information.
_______________________________________
______________________________________
Signature( Patient )
Date
_______________________________________
Print Name
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