OSHA STANDARD 1910.1030 - BLOODBORNE PATHOGENS:
Location and content of written plan and videotaped training of the following:
OSHA standard 29 CFR Sec. 1910.1030
HIV, HBV & HCV transmission and protection
Risk assessment categories
Universal and standard precautions
Personal Protective Equipment (PPE)
Exposure or symptom determination
Engineering controls and prevention
Work area regulations
Cleaning and laundry
This facility’s HBV policy and program
Exposure incident and post exposure follow up
Employee training
Tuberculosis
Post exposure incidence
Emergency action plans (fire, tornado, hurricane, etc.)

OSHA STANDARD 1910.1200 - HAZARD COMMUNICATION:
Location and content of written plan and videotaped training of the following:
Chemicals in the work environment
Proper labeling of chemicals
Material Safety Data Sheets (MSDS)
Methods of detecting released hazardous chemicals and means of protection
Chemical Spills
Training conducted by: Patricia M. Urban, LHRM
2191 9th Avenue North, Suite 120
St. Petersburg, Florida 33713
(727) 328-7775

Consent for Purposes of Treatment, Payment and Healthcare Operations
I consent to the use or disclosure of my protected health information by Pain Relief Centers for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Pain Relief Centers. I understand that diagnosis or treatment of me by Pain Relief Centers may be conditioned upon my consent as evidenced 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 treatment, payment or healthcare operations of the practice. Pain Relief Centers is not required to agree to the restrictions that I may request. However, if Pain Relief Centers agrees to a restriction that I request, the restriction is binding for Pain Relief Centers.

I have the right to revoke this consent, in writing, at any time, except to the extent that Pain Relief Centers has taken action in reliance on this consent.

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, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand I have a right to review Pain Relief Centers Notice of Privacy Practices prior to signing this document. The Pain Relief Centers Notice of Privacy Practices will be provided to me upon request. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of the Pain Relief Centers. The Notice of Privacy Practices for Pain Relief Centers is also posted at the front desk in the patient waiting area and on the Pain Relief Centers website at www.painreliefcenters.net. This Notice of Privacy Practices also describes my rights and the Pain Relief Centers duties with respect to my protected health information.

Pain Relief Centers 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 accessing the Pain Relief Centers website, calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.