Patients:

1.   Please print out the forms below: 

Patient Questionnaire

Authorization for Release of Medical and/or Behavioral Health Information

Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

Ambulatory Care Involvement in Care Discussions Form

2.   Fill in and fax or mail to:

University of Rochester Pain Treatment Center
180 Sawgrass Drive Suite 210
Rochester, NY 14620
Voice: (585) 242-1300
Fax: (585) 473-5007