HIPAA Information, the actual form for signature will be sent with your patient intake forms.

Metamorphosis Pain Management

In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Metamorphosis Pain Management is required by law to maintain the privacy of your protected health information (PHI) and to provide you with notice of our legal duties and privacy practices.

Acknowledgment of Receipt of Notice of Privacy Practices

A physical copy of this form will be sent to you for signature in your intake packet.

Authorization for Use and Disclosure of Health Information

Authorization for Metamorphosis Pain Management to use and disclose my health information as necessary for the following purposes:

– Treatment – including coordination with other healthcare providers involved in my care

– Payment – including insurance claims, billing, and collection activities

– Healthcare operations – such as quality assessment, training, and administrative purposes

Text Messaging Consent (Optional)

Metamorphosis Pain Management may use text messaging (SMS) to communicate with you about your care, including:

– Appointment reminders and confirmations

– Billing or insurance inquiries

– Follow-up instructions or treatment check-ins

– Occasional educational or promotional messages

Please note: Text messaging is not a fully secure or HIPAA-compliant communication method. While we take precautions to protect your information, there is some risk that messages could be accessed by unintended parties.

You may opt out at any time by replying “STOP” to any message or by notifying our office.

Patient Rights

I understand that:

– I have the right to request restrictions on the use and disclosure of my PHI

– I have the right to access and amend my medical records

– I have the right to file a complaint if I believe my rights have been violated