Get the free UCSF Patient Provider Agreement on Opioids - bayareaaetc.org
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Purpose: The purpose of this agreement is to protect your access to controlled substances and to protect our ability to prescribe for you. 1. Your provider has determined that you may be a candidate
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How to fill out ucsf patient provider agreement
How to fill out UCSF Patient Provider Agreement:
01
Obtain the UCSF Patient Provider Agreement form.
02
Read the form carefully and ensure that you understand all the terms and conditions mentioned in it.
03
Fill in the required personal information accurately, such as your full name, contact details, and date of birth.
04
Provide your insurance information if applicable. This may include your insurance company's name, policy number, and group number.
05
Review the sections related to your medical history and provide the necessary details. This may include any pre-existing conditions, allergies, or medications you are currently taking.
06
Complete the section related to emergency contact information. Provide the name, relationship, and contact number of the person to be contacted in case of an emergency.
07
Sign and date the form at the designated spaces. Ensure that your signature is legible and matches the name provided.
08
If you have any questions or concerns regarding the form, contact the UCSF healthcare provider or their office for assistance.
Who needs UCSF Patient Provider Agreement?
01
All patients seeking medical services or treatment from the University of California, San Francisco (UCSF) healthcare providers.
02
Patients who wish to receive specialized care, consultations, or procedures from UCSF medical professionals.
03
Individuals who have scheduled appointments or plan to visit UCSF facilities for medical purposes.
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